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Member Handbook
A helpful guide to getting services
Benefit Year 2019
Revised October 1, 2018
Arizona Complete Health-Complete Care Plan
Arizona Complete Care Plan
Covered services are funded under contract with AHCCCS.
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Table of �ontents Helpful Information................................................................................................................ 6
Arizona Complete Health-Complete Care Plan Member Services..................................... 6 Crisis Phone Number .......................................................................................................... 6 Mailing Address.................................................................................................................. 6 Website ............................................................................................................................... 6
Personal Information and Contact Information.................................................................. 6 Help in Another Language and for the Disabled: How Can I Get Help? ........................... 7
Nondiscrimination and Accessibility..................................................................................... 8 Los formularios para presentar quejas se encuentran en http://www.hhs.gov/ocr/office/file/index.html. ........................................................... 10 ................................................................................................................................................. 11 Welcome to Arizona Complete Health-Complete Care Plan............................................ 12
Arizona complete health-complete care plan member services........................................ 12 Care Management/Care Coordination .............................................................................. 13
Nurse Advice Line................................................................................................................. 13 Children’s Rehabilitative Services (CRS)........................................................................... 13 Emergency Care/ Urgent Care (After-Hours Care) .......................................................... 14 How to access Behavioral Health Crisis Services............................................................... 15
Crisis Services Available to you ....................................................................................... 16 How to Access Emergency Services While Out of the Service Area ................................ 16 Ensuring Culturally Competent Care................................................................................. 17
Interpretation Services ...................................................................................................... 17 Sign Language Interpreters and Auxiliary Aids ............................................................... 17 What Languages do providers speak?............................................................................... 18
........................................................................................................................................... 18 Assistance in another language and for individuals with disabilities: How can I get help?
Our Member Services is here to help................................................................................ 18 If you visit a provider not in our network .......................................................................... 18 How to get a printed provider directory............................................................................. 19 Where we serve ..................................................................................................................... 19
Your member ID card ....................................................................................................... 19 Member Responsibilities ...................................................................................................... 20
What to do when your family size changes or your member information changes.......... 20 If you move, you must tell us! .......................................................................................... 21
How Can I Change My Plan? .............................................................................................. 21 Changing your plan If you are a medicaid eligible member that has not been designated to be Seriously mentally ill (SMI): ................................................................................... 22
Family Voice & Decision Making........................................................................................ 23 Transition of Care Policy ..................................................................................................... 23 How do I use the emergency room appropriately?............................................................ 23
What to do in case of an emergency ................................................................................. 24 Transportation: How Do I Get Rides to Medical Appointments? ................................... 24
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Emergency Transportation................................................................................................ 24 Non-emergency transportation.......................................................................................... 25 wheelchair or stretcher ...................................................................................................... 25 Canceling rides to your appointments............................................................................... 25
What is Covered: What Kind of Health Care Can I Get from Arizona Complete Health-Complete Care Plan (AzCH-CCP)? .................................................................................... 26
Members Enrolled in the Comprehensive medical and dental program (CMDP) and Members Enrolled in the Department of Economic security/division of Developmental Disabilities (DDD) ............................................................................................................ 26 Medicaid Eligible Members with Integrated Physical Health and Behavioral Health Benfits administered by Arizona Complete Health-Complete Care Plan......................... 26 Medicaid/Medicare Dual Eligible Members..................................................................... 27 Grant Funded Programs for uninsured and UNderinsured Arizona Citizens ................... 27
Care Management/Care Coordination ............................................................................... 27 Physical Health Services for Members that are CMDP or DDD enrolled........................ 28 Disease Management ........................................................................................................ 29 Orthotics Care ................................................................................................................... 29 Additional Medical Covered Services for Medicaid-Enrolled Youth under the Age of 21 ........................................................................................................................................... 30
Covered Behavioral Health Services ................................................................................... 31 Table of Behavioral Health Covered Services.................................................................... 31 Non-Covered Services: What does AHCCCS Not Cover?................................................ 34 Exclusions and Limitations Table ....................................................................................... 35 Consent to Treatment ........................................................................................................... 37
Accessing Non-Title 19/21 services coordinated through the Regional behavioral health authority (RBHA) ............................................................................................................. 37 Housing Services .............................................................................................................. 38 Peer and family support resources .................................................................................... 38 End of Life Care/ Advance care planning......................................................................... 38
Specialty Services and Referrals.......................................................................................... 39 In-Network Referrals and Freedom of Choice of Providers ............................................. 40 Denial of Requests for Specialty Services ........................................................................ 40 Members who are American Indian.................................................................................. 41
Your Primary Care Provider (PCP) ................................................................................... 41 How to choose or change a Primary Care Provider (PCP) ............................................... 41 How can doctor visits help you stay healthy?................................................................... 42 How to make, change, or cancel an appointment ............................................................. 42
Appointment availability – How long should it take to see a provider ............................ 43 Well Visits ........................................................................................................................ 43 Well-Child Care / Early Periodic Screening, Diagnostic and Treatment (EPSDT)* ....... 44 Preventative and Well Care .............................................................................................. 46
Family Planning .................................................................................................................... 46 Maternity Care .................................................................................................................. 47 Pregnancy Identification ................................................................................................... 48 Prenatal Care..................................................................................................................... 48 High Risk Pregnancy ........................................................................................................ 50 Labor and Delivery Care................................................................................................... 50 Postpartum care................................................................................................................. 51
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HIV/AIDs Testing............................................................................................................. 51 Medically Necessary Pregnancy Terminations................................................................. 51
Dental Care............................................................................................................................ 52 Members under 21 years of age ........................................................................................ 52 Members 21 years of age and older .................................................................................. 53
Pharmacy Services ................................................................................................................ 53 What if a drug is not on the PDL/Formulary? .................................................................. 54 What if my request is denied?........................................................................................... 54 How to Fill a Prescription ................................................................................................. 54 What you need to know about your NEW prescription.................................................... 55 Refills................................................................................................................................ 55 What should I do if the pharmacy cannot fill my prescription? ....................................... 55 Exclusive Pharmacies ....................................................................................................... 56
How to Access Behavioral Health Services from Arizona Complete Health-Complete Care Plan ............................................................................................................................... 56
Receiving Behavioral Health services if you are enrolled with CMDP, DDD, or are Designated as seriously mentally ill ................................................................................. 57 Eligibility for Behavioral Health Services
Nine Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and
........................................................................ 57 How to Access Behavioral Health Services...................................................................... 57 Arizona’s Vision for the Delivery of Behavioral Health Services ................................... 58 The Twelve Principles for the Delivery of Services to Children:..................................... 58
Systems ............................................................................................................................. 61 Multispecialty Interdisciplinary Clinics ............................................................................. 62
Children’s Rehabilitative services (crs) PROVIDER: Multispecialty interdisciplinary clinics ................................................................................................................................ 62 How to make, change or cancel an appointment with a CRS Clinic ................................ 64
Children’s Rehabilitative Services (CRS)........................................................................... 65 conditions covered through the CRS program.................................................................. 65 EARLY CHILDHOOD SERVICES................................................................................. 66 HEAD START.................................................................................................................. 66 DEVELOPMENTAL SCREENING TOOLS .................................................................. 66
Special Assistance.................................................................................................................. 67 Member Advocacy Council .................................................................................................. 67 Approval and Denial Process ............................................................................................... 68 In-Network Referrals and Freedom of Choice of Providers............................................. 69 Copayments ........................................................................................................................... 70 Paying for Covered Services ................................................................................................ 73 Paying for non-covered services .......................................................................................... 73 Coordination Of Benefits (COB) ......................................................................................... 73 Special Information for our Members who have Medicare Coverage............................. 74
Important information for AHCCCS members With Medicare Part D Coverage (Dual eligible members).............................................................................................................. 75
Complaints: How to File and Complaint If I Am Unhappy ............................................. 75 HOW DO I ASK FOR A STATE FAIR HEARING?...................................................... 78 WHAT IS THE PROCESS FOR MY STATE FAIR HEARING? .................................. 79 HOW IS MY STATE FAIR HEARING RESOLVED?................................................... 79
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WILL MY SERVICES CONTINUE DURING THE APPEAL/STATE FAIR HEARING PROCESS? ....................................................................................................................... 79 Members determined to have a serious mental illness...................................................... 80
If you are a member that has been determined to have a Serious Mental Illness, please call Arizona Complete Health-Complete Care Plan and we can provide you additional information about your grievance and appeals rights. ..................................................... 80 Member Rights...................................................................................................................... 80
Exceptions to Confidentiality ........................................................................................... 82 What is Fraud and Abuse?................................................................................................... 84
How to Report Fraud and Abuse: ..................................................................................... 85 Community Resources.......................................................................................................... 85
Tobacco Education and Prevention .................................................................................. 85 Alzheimer’s Association................................................................................................... 85 Arizona Women Infants and Children (WIC)................................................................... 86 Health-e-Arizona Plus....................................................................................................... 86 AzLinks.gov...................................................................................................................... 86 Healthy Families Arizona ................................................................................................. 86 Pima Council on Aging..................................................................................................... 87 Area Agency on aging ...................................................................................................... 87 Pinal-Gila Council for senior citizens............................................................................... 87 seago area agency on aging............................................................................................... 87 Arizona Early Intervention Program (AzEIP) .................................................................. 88 Arizona Head Start............................................................................................................ 88 Community Information and Referral .............................................................................. 89 Child and Family Resources ............................................................................................. 89
Low Cost/Sliding Scale Health Care Providers.................................................................. 90 Advocacy Information .......................................................................................................... 90 Terms & Definitions ............................................................................................................. 92 Maternity Care Service Definitions..................................................................................... 95 Notice of Privacy Practices................................................................................................... 96
Uses and Disclosures of Your PHI That Require Your Written Authorization.............. 100 Individuals Rights ........................................................................................................... 101 Contact Information ........................................................................................................ 102
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__________________________________________________________
Helpful Information ARIZONA COMPLETE HEALTH-COMPLETE CARE PLAN MEMBER SERVICES
1-888-788-4408 or TTY/TDY 711 we are available 24 hours a day, seven days a week, 365 days a
year
CRISIS PHONE NUMBER
1-866-495-6735 (Southern Arizona Counties – Cochise, Graham, Greenlee, La Paz, Pima, Pinal,
Santa Cruz Counties)
1-602-222-9444 or 1-800-631-1314 (Central Arizona Counties – Maricopa)
1-877-756-4090 (Gila County)
MAILING ADDRESS
1870 W. Rio Salado Parkway
Tempe, AZ 85281
WEBSITE
azcompletehealth.com/completecare
Personal Information and �ontact Information My AHCCCS Member ID number
My Primary Care Provider
(PCP):
Hospital:
Pharmacy:
Case Manager:
Name Phone Number
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My Psychiatrist or Nurse:
HELP IN ANOTHER LANGUAGE AND FOR THE DISABLED: HOW CAN I GET HELP?
The Member Handbook and Provider Directory are provided at no cost to you. If you need this
handbook, provider directory, or other health information in another language or in an
alternative format such as large font, audio or accessible pdf, please contact Member Services
at 1-888-788-4408 or TTY/TDY 711. Or, visit us online at
azcompletehealth.com/members/medicaid.html.
Also, if you need an interpreter please call Member Services at least five (5) days before your
medical appointment to arrange the language assistance in time for your appointments. There
is no cost for the interpretation. You are not required to use family or friends to interpret for
you, and in fact, we discourage this from happening. Qualified interpreters should be used for
any language assistance needs
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Nondiscrimination and !ccessibility Discrimination is Against the Law
Arizona Complete Health-Complete Care Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Arizona Complete Health-Complete Care Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Arizona Complete Health-Complete Care Plan:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages
If you need these services, contact: Arizona Complete Health-Complete Care Plan Member Services at 1-888‐788‐4408 (TTY: 711) If you believe that Arizona Complete Health-Complete Care Plan failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Chief Compliance Officer, Cheyenne Ross. You can file a grievance in person, by mail, fax, or email. Your grievance must be in writing and must be submitted within 180 days of the date that the person filing the grievance becomes aware of what is believed to be discrimination. Submit your grievance to: Arizona Complete Health-Complete Care Plan Chief Compliance Officer-Cheyenne Ross, 1870 W. Rio Salado Parkway, Tempe, AZ 85281. Fax: 1866.388.2247 Email: [email protected] You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at U.S. Department of Health and Human Services; 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201; or by phone: 1-800-368-1019, 1800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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La discriminación es contra la ley Arizona Complete Health-Complete Care Plan (AzCH-CCP) cumple con las leyes Federales de derechos civiles correspondientes y no discrimina con base en la raza, el color, la nacionalidad, la edad, la discapacidad o el sexo. Arizona Complete Health-Complete Care Plan no excluye a las personas ni las trata en forma distinta debido a su raza, color, nacionalidad, edad, discapacidad o sexo. Arizona Complete Health-Complete Care Plan:
• Proporciona, sin cargo alguno, ayudas y servicios a las personas con discapacidades para que se comuniquen en forma eficaz con nosotros, como: intérpretes de lenguaje de señas calificados.
• Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles y otros formatos).
• Proporciona, sin cargo alguno, servicios de idiomas a las personas cuyo idioma primario no es el inglés, como: intérpretes calificados e información por escrito en otros idiomas.
Si necesita estos servicios, llame al Centro de Contacto con el Cliente al: 1- 888‐788‐4408 (TTY: 711) Si considera que Arizona Complete Health-Complete Care Plan no ha proporcionado estos servicios o que ha discriminado de otra manera con base en la raza, el color, la nacionalidad, la edad, la discapacidad o el sexo, puede presentar una queja ante el Director General de Cumplimiento (Chief Compliance Officer), Cheyenne Ross. Puede presentar la queja en persona o por correo, fax, o correo electrónico. Su queja debe estar por escrito y debe presentarla en un plazo de 180 días a partir de la fecha en que la persona que presenta la queja se percate de lo que se cree que es discriminación. Presente su queja a: Arizona Complete Health-Complete Care Plan, Chief Compliance Officer-Cheyenne Ross, 1870 W. Rio Salado Parkway Tempe, AZ 85281. Fax: 1-866.388.2247 correo electrónico: [email protected]
También puede presentar una queja de derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de Estados Unidos, electrónicamente mediante el Portal de Quejas de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal a U.S. Department of Health and Human Services; 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201; o por teléfono: 1-800-368-1019, 1-800537-7697 (TDD).
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Los formularios para presentar quejas se encuentran en http://www.hhs.gov/ocr/office/file/index.html.
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arizona complete health.
Attention: If you speak a language other than English, oral interpretation and written translation are available to you free of charge to understand the information provided. Call 1-888-7884408 (TTY: 711 ).
Spanish Si habla espariol, dispone sin cargo alguno de interpretaci6n oral y traducci6n escrita. Llame al 1-888-788-4408 (TTY: 711 ). Si habla español, dispone sin cargo alguno de interpretación oral y traducción escrita. Llame al 1-888-788-4408 (TTY: 711). Din.C k ·ehji y3.nilt:i •go ata • han.c · nil h61Q d66 na.alt.soos ea.a Din.C k· e h ji b ee
Navajo b ik·e·ashchijgo nic h •t . cidoolniilg o b ee haz** ald6. ciko dii ea.a aee t •aa jitk•e k 6t•cego nich "! · ""·a.cc. K o_»· h olne" 1-888- 788-4408 (TTY: 711).
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Kung ikaw ay nagsasalita ng Tagalog, mayroong libreng oral na Tagalog interpretasyon at nakasulat na pagsasalin na maaari mong gamitin.
Tumawag sa 1-888-788-4408 (TTY: 711 ).
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French Si vous parlez fran9ais, vous disposez gratuitement d'une interpretation orale et d'une traduction ecrite. Appelez le 1-888-788-4408 (TTY : 711 ). Fur alle, die Deutsch sprechen, stehen kostenlose Dolmetscher- und
German Obersetzungsservices zur VerfUgung. Telefon: 1-888-788-4408 (TTY: 711 ). ECJWI Bbl roeop111Te no-pycCKVI, ycnyrn YCTHOro VI nVICbMeHHOro nepeBO,Qa
Russian npe,QOCTaBJl.RIOTC.R BaM 6ecnnaTHO. 3BOHVITe no TenecpoHy 1-888-7884408 (TTY: 711 ).
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Serbo-Croatian Ako govorite srpsko hrvatski, usmeno i pismeno prevodenje vam je dostupno besplatno. Nazovite 1-888-788-4408 (TTY: 711 ).
Thai 'ltl1flFJrn'\-:l\;J.fl1'1f11'Vlt1 L·n:i'lu~m':i~1:1.1Lrn:::LL1hm1ml1':i L\;'lt11:1.l:i'll'i1'l'lf~1t1 'i:'Vl':iAWVi
1-888-788-4408 (TTY: 711)
Welcome to !rizona �omplete Health-�omplete �are Plan
Welcome to Arizona Complete Health-Complete Care Plan your Arizona Complete Care Plan
(ACC) Thank you for placing your trust in us. We look forward to serving you.
In this handbook, we use “you” and “your” to mean “the !H���S member/” We use “we,” “us,”
“our” and “our plan” to mean “Arizona Complete Health-Complete Care Plan/” Only the
member can get the benefits talked about in this handbook. Covered services are funded under
contract with Arizona Health Care Cost Containment System (AHCCCS).
ARIZONA COMPLETE HEALTH-COMPLETE CARE PLAN MEMBER SERVICES
Our Member Services Department (Member Services) is staffed by representatives who speak
several languages, including English and Spanish. Member Services also uses a telephone
interpreter service for members who speak a language that is not available within the
department. You can call Member Services at 1-888-788-4408, TTY/TDY 711. If you speak
another language other than English or Spanish, call Member Services and we will help get an
interpreter to assist with the phone call.
When calling Member Services, please have the following information ready:
➢ Your name, your AHCCCS ID number, your date of birth, the phone number and address
on file.
➢ You will also need a pen and paper to write down important information we will give
you.
Some of the ways Member Services can help you:
➢ Answer questions about your covered services, benefits, and co-pays
➢ Provide information about doctors, nurse practitioners, and physician assistants
➢ Provide information about programs available to members
➢ Help you choose or change your PCP
➢ Help you schedule a ride to your doctor or medical appointments
➢ Help you make, change or cancel your medical appointments
➢ Provide you with dentist or specialist information
➢ Help you if you have a complaint or problem
➢ Help you with your rights as a member
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➢ Help you schedule a language interpreter for your medical appointments if you cannot
communicate with your doctor. This service is provided at no cost to you.
➢ Help you change your phone number and address with AHCCCS.
➢ If you are currently being treated for conditions such as diabetes, cancer, asthma,
behavioral health, HIV/AIDS, or any disability, call Member Services immediately. We
will refer you to an Integrated Care Manager to make sure you are getting the care you
need.
CARE MANAGEMENT/CARE COORDINATION Care Management and Care Coordination are a benefit we offer to Medicaid Enrolled members
at no cost to you. Our goal is to help you be healthy through education and your own health
care planning. Our nurses, behavioral health professionals and care coordinators will help you
and/or a family member get the care you need, understand your medicines, help you obtain
names and numbers for community resources, and work with you and your PCP and /or Health
Home to get any other services you need to keep you healthy. If you want a Care Manager,
please call Member Services at 1-888-788-4408 (TTY/TDD: 711) for a referral. Your PCP and/or
Behavioral Health Home can refer you to Care Management/Care Coordination as well.
If you would like to learn more about the information in this Member Handbook, please call
Arizona Complete Health-Complete Care Plan Member Services at: 1-888-788-4408, TTY/TDY
711 or visit our website at azcompletehealth.com/completecare
Nurse !dvice Line Arizona Complete Health-Complete Care Plan has a Nurse Advice Line available 24 hours a day,
7 days a week for members. You can call anytime to get assistance from a nurse or if you have
questions about your health.
To speak to a nurse, please call: 1-866-534-5963
�hildren’s Rehabilitative Services (�RS) What is CRS? �hildren’s Rehabilitative Services (�RS) is a designation given to certain !H���S members who have qualifying health conditions. Members with a CRS designation can get the same AHCCCS covered services as non-CRS AHCCCS members and are able to get care in the community, or in clinics called multispecialty interdisciplinary clinics (MSIC). MSICs bring many specialty providers together in one location. Your health plan will assist a member with a CRS designation with closer care coordination and monitoring to make sure special healthcare needs are met.
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Eligibility for a CRS designation is determined by the AHCCCS Division of Member Services (DMS).
Who is Eligible for a CRS Designation? AHCCCS members may be eligible for a CRS designation when they are: ➢ Under age 21; and ➢ Have a qualifying CRS medical condition.
The medical condition must: ➢ Require active treatment; and ➢ Be found by AHCCCS DMS to meet criteria as specified in R9-22-1301-1305.
Anyone can fill out a CRS application including a family member, doctor, or health plan representative. To apply for a CRS designation mail or fax: ➢ A completed CRS application; and ➢ Medical documentation that supports that the applicant has a CRS qualifying condition
that requires active treatment.
AzCH will provide medically necessary care for physical and behavioral health services and care for the CRS condition.
If you have questions about the CRS program, please call Arizona Complete Health-Complete
Care Plan at 1-888-788-4408, TTY/TDY 711.
Emergency �are/ Urgent �are (!fter-Hours �are) For life threatening emergencies always call 911. Prior Authorization is not required for
emergency services.
Should I go to the Emergency Room or Urgent Care?
Examples of Emergency Room Symptoms:
➢ Extreme Shortness of Breath
➢ Fainting
➢ Poisoning
➢ Chest Pains
➢ Uncontrolled Bleeding
➢ Seizures
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Examples of Urgent Care Symptoms:
➢ Vomiting for more than 6 hours (if young child, call PCP)
➢ Diarrhea for more than 6 hours (if young child, call PCP)
➢ Sprained ankle
➢ Minor burns and rashes
➢ A minor allergic reaction
➢ Flu, sore throat with fever, earaches
After-Hours Care (Urgent Care)
An Urgent Care Center is a great place to get help because they usually have extended hours
(after hours), doctors to treat common problems, and can see you quickly (usually in less than
an hour). Urgent Care centers can help you with ear infections, sore throats, urinary tract
infections, minor cuts and burns, sprains, and other common health issues. Urgent Care can be
used for problems your doctor would normally help with. Member Services can help you find an
Urgent Care center near you.
Emergency Room
Emergency rooms are for the treatment of emergency medical conditions, such as broken
bones, severe pain, possible medicine overdose or poisoning, unconsciousness, excessive
bleeding, seizures, chest pains or difficulty breathing.
If you need to see a doctor right away, contact your doctor for advice or to make an
appointment. If your doctor is unable to see you, or the office is not open, please consider
going to the closest Urgent Care center. Member Services can help you find an Urgent Care
center near you.
How to access �ehavioral Health �risis Services For life threatening emergencies always call 911. Prior Authorization is not required for
emergency services.
If you are experiencing a behavioral health crisis, call the Envolve People Care Crisis Line 1-866-
495-6735, (TTY/TDY 711) if you are in in Pima, Yuma, Pinal, Graham, Greenlee, Santa Cruz,
LaPaz or Cochise counties. If you live in Maricopa County you can reach the 24-hour Crisis Line
at 1-602-222-9444 or 1-800-631-1314 (TTY/TDY: 711). If you live in Gila County you can contact
the crisis line at 1-877-756-4090.
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The Crisis Line offers immediate and confidential help 24 hours a day, 7 days a week, 365 days a
year to anyone experiencing a behavioral health crisis, regardless of insurance coverage.
CRISIS SERVICES AVAILABLE TO YOU
You are able to get crisis services, even if you are not Title 19/21 eligible (i.e., not eligible for
AHCCCS/not on Medicaid) or determined to have a Serious Mental Illness. Crisis services
available to you include:
➢ Crisis Intervention phone services, including a toll free number, available 24 hours per
day, 7 days a week
➢ Mobile Crisis Intervention services, available 24 hours per day, 7 days a week;
➢ 23-hour crisis observation/stabilization services, including detoxification services, and as
funding allows, up to 72 hours of additional crisis stabilization; and
➢ Substance abuse-related crisis services, including follow-up services for stabilization.
How to !ccess Emergency Services While Out of the Service !rea
You may need emergency services while you are away from home and out of the Arizona
Complete Health-�omplete �are Plan service area/ This is called “out of area care/” !rizona
Complete Health-Complete Care Plan. You have a right to use any hospital or other setting for
emergency care. If you need out of area emergency care:
➢ Go to a hospital or crisis center and ask for help; ➢ Ask the hospital or crisis center to call 1-888-788-4408, TTY/TDY 711. ➢ The hospital or crisis center will contact Arizona Complete Health-Complete Care Plan
for approval to services. ➢ For life threatening emergencies always call 911. Prior Authorization is not required for
emergency services.
If you experience an emergency, emergency services are available to you at any hospital or other emergency room facility (in or out of network). Emergency services do not require prior authorization.
You can choose any hospital or other setting for emergency care. However, there are certain
emergency settings within the Arizona Complete Health-Complete Care Plan network that may
be easier for you to use.
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Ensuring �ulturally �ompetent �areWe value you. We understand that there are many diverse cultural and ethnic backgrounds of
people in Arizona. We know that your health is affected by your beliefs, culture, and values.
We want to help you keep and maintain good health and good relationships with doctors and
other providers who understand your needs. If you feel that there is a problem, please contact
us. We will help you find a provider who will better understand your personal needs. We
provide language assistance, including Sign Language interpreters, at no cost to you. We can
also help you find a provider that speaks your language. If you cannot communicate with your
provider because of a language barrier, we can schedule an interpreter to help with your
appointment; please contact Member Services at 1-888-788-4408, (TTY/TDY 711).
Call us and let us know if we have overlooked anything that is important to you. We want to
help. We want you to be comfortable with our services. If you would like to share cultural
information that you feel is important to your health care, or select a provider based on
convenience, location, disability accommodations, or cultural preference, please call Member
Services at 1-888-788-4408, (TTY/TDY 711).
If you need any written member materials translated, or materials in alternate formats
including large print, please call Member Services, we can provide those to you.
PRINTED INFORMATION FOR MEMBERS
If you need any written member materials translated, or materials in alternate formats
including large print or Braille, please contact your provider or Arizona Complete Health-
Complete Care Plan Member Services at 1-888-788-4408 or TTY/TDY: 711 or visit our website
azcompletehealth.com/completecare to receive your materials in an alternative format
INTERPRETATION SERVICES
We provide language assistance, including Sign Language interpreters, at no cost to you. We
can also help you find a provider that speaks your language. If you cannot communicate with
your provider because of a language barrier, we can schedule an interpreter to help with your
appointment; please contact Member Services at 1-888-788-4408, (TTY/TDY 711).
SIGN LANGUAGE INTERPRETERS AND AUXILIARY AIDS
If you are deaf or hard of hearing, you may ask that your provider provide auxiliary aids or
schedule a Sign Language Interpreter to meet your needs. Your provider has to provide these
services to you.
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Auxiliary aids include computer-aided transcriptions, written materials, assistive listening
devices, or systems, closed and open captioning, and other effective methods of making aurally
delivered materials available to individuals with hearing loss.
Sign Language Interpreters are skilled professionals certified to provide interpretation, usually
in American Sign Language, to the deaf. To find a listing of sign language interpreters and for
the laws regarding the profession of interpreters in the State of Arizona, please visit the Arizona
Commission for the Deaf and the Hard of Hearing at www.acdhh.org or call (602) 542-3323 (V);
(602) 364-0990 (TTY); 800-352-8161 (V/TTY); (480) 559-9441 (Video Phone).
WHAT LANGUAGES DO PROVIDERS SPEAK?
A listing of all available providers, their locations, telephone numbers, and languages spoken
can be found online at azcompletehealth.com/completecare if you would like to select a
provider based on convenience, location, disability accommodations, or cultural preference,
please call Arizona Complete Health-Complete Care Plan Member Services.
ASSISTANCE IN ANOTHER LANGUAGE AND FOR INDIVIDUALS WITH DISABILITIES: HOW CAN I GET HELP?
If you have a physical disability, network provider offices should accommodate you. You can call
Member Services to find a provider who can meet your needs at 1-888-788-4408 (TDY/TDD:
711), or search for a provider online with our Find a Provider tool at
azcompletehealth.com/completecare
OUR MEMBER SERVICES IS HERE TO HELP
Arizona Complete Health-Complete Care Plan will help you choose a provider from within the
provider network. If you would like to select a provider based on convenience, location,
disability accommodations, or cultural preference, please call Arizona Complete Health-
Complete Care Plan Member Services. You will need to contact the provider to make, change,
or cancel your appointments. You may also contact Arizona Complete Health-Complete Care
Plan if you would like assistance with making, changing, or canceling your appointments.
If you visit a provider not in our network You are required to access services through Arizona Complete Health-Complete Care Plan
contracted network providers. You can find an Arizona Complete Health-Complete Care Plan
contracted provider by visiting our website at azcompletehealth.com/completecare and click on
the Find a Provider link or you can call our Member Services Line for assistance. If you visit a
provider not in our network, the provider will likely not be paid for the services you receive and
you may be billed for the services by the provider. Exceptions to this requirement include
Emergency Services and out-of-network single-case agreements approved and authorized by
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Arizona Complete Health-Complete Care Plan Utilization Management department. You may
receive emergency services from the nearest emergency center, whether that Center is
contracted with Arizona Complete Health-Complete Care Plan or not. This includes out-of-state
Emergency Centers when traveling out-of-state. If you do not find a provider contracted with
Arizona Complete Health-Complete Care Plan that can meet your treatment needs, please call
Member Services for assistance. If Arizona Complete Health-Complete Care Plan is unable to
locate an in-network provider to meet your treatment needs, our team will enter into a special
agreement with an out-of-network provider for you.
How to get a printed provider directory The Arizona Complete Health-Complete Care Plan provider directory is available at no cost to
you. For a copy, please call Member Services at 888-788-4408 TTY/TDY 711 or you can view a
printable copy on our website: azcompletehealth.com/completecare
Where we serve Arizona Complete Health-Complete Care Plan serves members in the following counties:
Cochise, Gila, Graham, Greenlee, La Paz, Maricopa, Pima, Pinal, Santa Cruz and Yuma including
the San Carlos Tribal area.
Arizona Complete Health-Complete Care Plan is a Managed Care Plan. A Managed Care Plan is a
health plan that provides care to its members through a select group of doctors, hospitals, and
pharmacies. You and your Primary Care Physician (PCP) play an important role in your managed
care plan. Your PCP is the coordinator of your care and helps decide what services you need. It
is your rresponsibility to see your PCP and/or your Behavioral Health Home and talk with them
about your health.
Contact the Arizona Complete Health-Complete Care Plan Member Services with any questions
or concerns about your health benefits or medical services.
YOUR MEMBER ID CARD
If you have an !rizona driver’s license or state issued ID, !H���S will obtain your picture from
the Arizona Department of Transportation Motor Vehicle Division (MVD). The AHCCCS eligibility
verification screen that providers see contains your picture (if available) and details on your
coverage.
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Only you are allowed to use your Arizona Complete Health-Complete Care Plan ID card for
services. Never lend, sell, or allow someone to use your card. This is against the law, and you
might lose your AHCCCS eligibility. Legal action may also be taken against you.
It is your responsibility to protect your ID card. Remember: any misuse of the card, including
loaning, selling or giving it to others could result in loss of your eligibility and/or legal action. It
is very important that you keep your ID card in a safe place and do not throw it away.
Member Responsibilities
As an Arizona Complete Health-Complete Care Plan member, you can contribute to your health.
As a member you have the responsibility to:
➢ Provide, to the extent possible, information needed by professional staff to care for you ➢ Follow instructions and guidelines given by those providing health care ➢ Know the name of your assigned PCP (Primary Care Provider) ➢ Schedule appointments during office hours whenever possible instead of using urgent
care facilities or emergency rooms ➢ Arrive for appointments on time ➢ Notify the provider in advance when it is not possible to keep an appointment ➢ Bring immunization records to every appointment for children ages 18 and younger ➢ Share Information
o If you do not understand your health condition or treatment plan, ask your doctor to
explain
o Give your doctors, providers and care manager all the facts about your health
problems, past illnesses, hospital stays, all medications, shots and other health
concerns.
➢ Participate in Recovery
o Know the name of your doctors and/or your care manager
o Participate in creating your Service Plan
o Follow the instructions that you and your doctors have agreed on, including the
instructions of nurses and other health care professionals
WHAT TO DO WHEN YOUR FAMILY SIZE CHANGES OR YOUR MEMBER INFORMATION CHANGES
Each new person in your family must be made eligible for AHCCCS. You must call the office that
made you eligible for AHCCCS to add a new member or if any family member leaves and your
family becomes smaller.
• DES www.healthearizonaplus.gov or 1(855)HEA-PLUS (1-855-432-7587) • KidsCare www.healthearizonaplus.gov or 1(855)HEA-PLUS (1-855-432-7587)
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• SSI MAO www.healthearizonaplus.gov or 602-417-5010/1-800-528-0142 Outside Maricopa County
• Social Security Administration (1-800-772-1213) • ALTCS Local Offices
Please remember it is important to report a new baby immediately after the birth so that your baby will be eligible for services.
If any of your information changes, such as your phone number or address, please call Member
Services at 1-888-788-4408 so we can assist you with making those changes.
If you have any questions, call Arizona Complete Health-Complete Care Plan Member Services.
IF YOU MOVE, YOU MUST TELL US!
As a member of our plan, your service area is southern and central Arizona. If you move out of the United States, the state of Arizona, or out of southern or central Arizona, your current plan will no longer be valid. Before you move, call Member Services to update your address. We can often update your address with the AHCCCS eligibility office.
You could lose your care with AHCCCS if you do not tell them you are moving.
Other places you should notify include: ➢ Your PCP ➢ The Supplemental Security Income (SSI) office, if you are receiving SSI benefits ➢ Department of Economic Security (DES), if you receive TANF, food stamps ➢ For KidsCare (Title XXI) members, please call AHCCCS at 1-602-417-5437 or the toll-free
statewide number, 1-877-764-5437.
Call Arizona Complete Health-Complete Care Plan Member Services if you have questions about your enrollment or call AHCCCS at 1-800-654-8713 or 1-602-417-4000.
How �an I �hange My Plan? If you are a member that is eligible for Medicaid and has not been determined to have a Serious Mental Illness, the box below tells you how you can change your health plan.
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CHANGING YOUR PLAN IF YOU ARE A MEDICAID ELIGIBLE MEMBER THAT HAS NOT BEEN DESIGNATED TO BE SERIOUSLY MENTALLY ILL (SMI):
Annual Enrollment Choice (AEC)
You may change your health plan on your AHCCCS enrollment anniversary date each year. AHCCCS will send you information 60 days before your anniversary date. The information will tell you how to change your health plan.
Health Plan Changes
There are certain reasons why you may change your health plan outside of your AEC period.
Please call AHCCCS if you need to change your plan for the following reasons:
1. You were not given a choice of health plans 2. You did not get your AEC letter from AHCCCS 3. You got your AEC letter but were not able to take part in your AEC due to things that were out of
your control 4. Your family members have another health plan 5. You are a member of a special group and need to have the same health plan as the special group 6. You lost your AHCCCS insurance and came back on AHCCCS within 90 days and were not put back
on the health plan you had before 7. Newborns are assigned to the mother’s plan. You have 90 days to ask AHCCCS to change your
newborn’s health plan. 8. You moved to a county where our health plan is not provided
Call AHCCCS at 1-855-432-7587 or 602-417-7000.
Health Plan Changes for Medical or Care Concerns
You may be able to change your Health Plan for medical, health reasons or continuity of care. If our doctors cannot give you the care you need we will review your request. We will tell you if you can change your plan. Arizona Complete Health will also check to see if your concern is due to a quality of care or delivery of care issue. We will work to address your concerns.
Please call Member Services if you need to change your health plan for any of the above
reasons. Call 1-888-788-4408. Ask to speak to the Appeals and Grievance Department. Or
you may write to us at:
Arizona Complete Health Attn: Appeals & Grievances Department
1870 W. Rio Salado Parkway Tempe, AZ 85281
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Family Voice & Decision Making Our healthcare providers are expected to include responsible family members and other
authorized individuals as decision-makers in the treatment planning process. It is important
that responsible family members and other authorized individuals attend as many discussions
as possible regarding treatment planning for your child. That way, as the decision-maker, you
will be able to make the most informed decisions regarding health care for your child. If you
feel your voice is not being heard please contact our Advocacy Team for help by calling
Member Services at 1-888-788-4408 or TTY/TDY 711.
Transition of �are Policy We want to help you if you are moving and you have a new AHCCCS plan. We can help transition your care to your new health plan and providers.
Arizona Complete Health-Complete Care Plan will help with coordination of care for all of our
members during the following types of transitions: between Managed Care Organizations,
changes in service areas, and/or health care providers. Certain members may require additional
help during a period of transition. If you have questions about coordination of care when
making changes, please call Member Services at 1-888-788-4408 or TTY/TDY 711.
Arizona Complete Health-Complete Care Plan shall receive information from your past health
plan or will contact your new health plan to assist with coordination of your care to ensure your
care will continue without disruption. If you have concerns regarding a potential transition of
your care, please contact Member Services at 1-888-788-4408 or TTY/TDY 711.
How do I use the emergency room appropriately? If your life is in immediate danger, call 911. If you need to see a doctor right away, contact your PCP for advice or to make an appointment. If your doctor is unable to see you, or the office is not open, please consider going to the closest Urgent Care center. Member Services can help you find an Urgent Care center near you.
Should I go to the Emergency Room or Urgent Care?
Examples of Emergency Room Symptoms:
➢ Extreme Shortness of Breath
➢ Fainting
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➢ Poisoning
➢ Chest Pains
➢ Uncontrolled Bleeding
➢ Seizures
Examples of Urgent Care Symptoms:
➢ Vomiting for more than 6 hours (if young child, call PCP)
➢ Diarrhea for more than 6 hours (if young child, call PCP)
➢ Sprained ankle
➢ Minor burns and rashes
➢ A minor allergic reaction
➢ Flu, sore throat with fever, earaches
WHAT TO DO IN CASE OF AN EMERGENCY
Medical emergencies are sudden conditions, which are life or death situations. They may lead to disability or death if not treated as soon as possible. No Prior Authorization is necessary for emergency care.
If you feel your symptom is an emergency, call 911 or go to the nearest Emergency
Department. As a member of our plan, you have the right to seek Emergency Service at any
hospital or other Emergency Room facility (in or out of network). Please tell the Emergency
Department staff that you are an Arizona Complete Health-Complete Care Plan member and
show your ID card. If you are unable to do this, have a family member or friend tell the
Emergency Department staff that you are a member of our plan.
What if you need Emergency Care out of our service area? Our plan will pay for emergency care while you are out of the county or state. If you need emergency care, show your Arizona Complete Health-Complete Care Plan ID card so the doctors can notify us.
Transportation. How Do I Get Rides to Medical !ppointments?
EMERGENCY TRANSPORTATION
Your condition is a medical emergency when your life, body parts or bodily functions are at risk of damage or loss unless immediate care is received. Emergency transportation is a covered
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benefit.
In cases of emergency (in a life-threatening situation) call 911.
Some examples of Emergency Symptoms include extreme Shortness of Breath, fainting,
poisoning, chest pains, uncontrolled bleeding, and seizures.
Prior Authorization is not required for emergency services, including emergency transportation.
NON-EMERGENCY TRANSPORTATION
Members can get rides to doctor appointments in several ways. The easiest way is to find a ride with a family member or a friend. If family is unavailable, and you have a Behavioral Health Home, your �ehavioral Health Home is required to assist you with transportation/ If you don’t have a Behavioral Health Home or your Behavioral Health Home is unable to meet your transportation needs, please contact Member Services. We will arrange for transportation for medical appointments. Please contact us three (3) days before the appointment.
You can call Member Services on weekends and holidays, for transportation to urgent care centers when you are sick.
Always remember to dial 911 in a true medical emergency.
If you call to get a ride to a medical appointment, please be ready to tell the representative the following: ➢ Your name, AHCCCS ID number, date of birth, address, phone number (for verification
purposes). ➢ The date, time and address of your medical visit. ➢ If you need a ride one way or a round trip. ➢ Your travel needs (wheelchair, stretcher or other). ➢ Any special needs (oxygen, IVs, someone who needs to travel with you, an extra-wide or
electric wheelchair, a high-top vehicle, etc.). ➢ Children under the age of 5 require a car seat. Children ages 5 through 7 and shorter than 4’9” require a booster/ You must provide a car seat for your child for the trip/
WHEELCHAIR OR STRETCHER
If you need a wheelchair or a stretcher for your ride to a routine doctor’s visit, patient transport services vans can take you there and bring you back. You must call Member Services to set up these rides at least three (3) to four (4) working days before your appointment date.
CANCELING RIDES TO YOUR APPOINTMENTS
If you cancel your doctor or dentist visit, you must also call Member Services to cancel your ride to your visit. Please call us at 1-888-788-4408 or TTY/TDY 711.
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What is �overed: What Kind of Health �are �an I Get from !rizona �omplete Health-�omplete �are Plan (!z�H-��P)?
In order for you to get health care service through our Plan, the service must be both:
➢ A Covered Benefit based on your coverage with AHCCCS, and
➢ Medically Necessary.
! “�overed �enefit” means that you can get this service through !H���S and Arizona Complete
Health-Complete Care Plan/ “Medically Necessary” means that a covered service is provided by
a physician or other licensed practitioner of the healing arts within the scope of practice under
state law to prevent disease, disability or other adverse health conditions or their progression,
or prolong life.
Arizona Complete Health-Complete Care Plan covers members from many groups. Please see
below to see what services are covered for you.
MEMBERS ENROLLED IN THE COMPREHENSIVE MEDICAL AND DENTAL PROGRAM (CMDP) AND MEMBERS ENROLLED IN THE DEPARTMENT OF ECONOMIC SECURITY/DIVISION OF DEVELOPMENTAL DISABILITIES (DDD)
If you are enrolled with the AHCCCS Community Medical and Dental Plan (CMDP) or the
Arizona Department of Economic Security/Division of Developmental Disabilities (DDD) and
are also enrolled with Arizona Complete Health-Complete Care Plan, you are eligible for the
full array of AHCCCS Behavioral Health Services listed below through our Plan. Your physical
health services will continue to be provided through your affiliated health plan. Arizona
Complete Health-Complete Care Plan will actively coordinate services with your health plan
on your behalf.
MEDICAID ELIGIBLE MEMBERS WITH INTEGRATED PHYSICAL HEALTH AND BEHAVIORAL HEALTH BENFITS ADMINISTERED BY ARIZONA COMPLETE HEALTH-COMPLETE CARE PLAN
If you are a Medicaid enrolled adult or child and enrolled in the Arizona Complete Health-Complete Care Plan and not dually enrolled in CMDP or DDD as described above, you are
26
eligible to receive both your physical health and behavioral health care through Arizona Complete Health-Complete Care Plan.
MEDICAID/MEDICARE DUAL ELIGIBLE MEMBERS
If you are a “dual eligible” member (Medicare and Medicaid enrolled), it often means that you
have additional benefits that may not be covered under AHCCCS. When we know about your
other insurance, it helps us coordinate the care you receive with the other plan. If you have
Medicare coverage and you see a doctor that is not on our plan, the charges may not be
covered. If you choose to do that without our approval, we may not pay for those services
because they were done by a doctor that is not on our plan. It is important that you work with
your PCP and/or Health Home to be referred to the right doctors. (This requirement does not
include emergency services. You do not need approval to receive emergency services.) We will
not cover copays or deductibles for services provided outside of the Arizona Complete Health-
Complete Care Plan contracted Network without Prior Authorization.
GRANT FUNDED PROGRAMS FOR UNINSURED AND UNDERINSURED ARIZONA CITIZENS
If you live in Cochise, Graham, Greenlee, La Paz, Pima, Pinal, Santa Cruz, or Yuma Counties, and
are experiencing a Substance Use Disorder (SUD) or Opioid Use Disorder (OUD), you very well
may be eligible for SUD treatment services through Arizona Complete Health-Complete Care
Plan. Call our Member Services for more information and clarification about coverage.
�are Management/�are �oordination Care Management and Care Coordination are a benefit we offer to Medicaid Enrolled members at no cost to you. Our goal is to help you be healthy through education and your own health care planning. Our nurses, behavioral health professionals and care coordinators will help you and/or a family member get the care you need, understand your medicines, help you obtain names and numbers for community resources, and work with you and your PCP and /or Health Home to get any other services you need to keep you healthy. If you want a Care Manager, please call Member Services at 1-888-788-4408 (TTY/TDD: 711) for a referral. Your PCP and/or Behavioral Health Home can refer you to Care Management/Care Coordination as well.
Medicaid �overed Physical Health ServicesThe following services are available to Medicaid enrolled members that are not CMDP enrolled or DDD enrolled. See the boxes below for details if you belong to either of these categories or if you are not enrolled. Call Member Services or talk to your PCP and/or Health Home for more information about these services.
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PHYSICAL HEALTH SERVICES FOR MEMBERS THAT ARE CMDP OR DDD ENROLLED
Members that are CMDP enrolled or DDD enrolled are only eligible to receive behavioral health services through Arizona Complete Health-Complete Care Plan Regional Behavioral Health Authority (RBHA). Members enrolled in CMDP and/or DDD receive physical health services through their associated health plan.
➢ Ambulance for emergency care ➢ Audiology services to evaluate hearing loss on both outpatient and inpatient basis ➢ Care while you are pregnant ➢ Case management ➢ Checkups for children*, pregnant individuals, and Qualified Medicare Beneficiary (QMB) ➢ �hildren’s services including routine dental care ➢ Chiropractic services are covered services for adults over the age of 21, and Qualified
Medicare Beneficiary (QMB) Dual members. ➢ Emergency medical and surgical services related to dental (oral) care ➢ Adult emergency dental benefits up to $1,000 per contract year (Oct 1- Sept 30) when
provided by a licensed physician or dentist. Adult emergency dental covers medically necessary emergency dental care and extractions who have an acute disorder of oral health resulting in severe pain and/or infection as a result of trauma or other acute conditions. Exception to the $1000 emergency dental benefit is for members undergoing organ or tissue transplantation or having cancer of the jaw, neck or head, please call your care manager to assist with care coordination.
➢ Dialysis ➢ Disease Management ➢ Emergency or Urgent Care medical treatment ➢ Eyeglasses or contacts for children, or adults only after cataracts are removed ➢ Family planning / birth control ➢ Foot and ankle care services for adults, including wound care, treatment of pressure ulcers,
fracture care, reconstructive surgeries, and limited bunionectomy services. ➢ Health care services including screenings, diagnosis and medically necessary treatments ➢ Home and Community Based Services (HCBS) ➢ Hospital care ➢ Blood and blood plasma ➢ Intensive care ➢ Laboratory, x-ray and imaging services ➢ Medicines ➢ Nursing care ➢ Operating room and hospital care ➢ Services of doctors, surgeons, specialists
➢ Speech Therapy is covered for all members receiving inpatient hospital (or nursing facility services). Outpatient speech therapy is only covered for members under age 21 and qualified Medicare beneficiaries.
➢ Outpatient physical therapy and occupational therapy to restore a level of function and/or
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maintain function is limited to 30 visits per contract year for members 21 years of age and older and unlimited for members under age 21 and qualified Medicare Beneficiaries. Medicare beneficiaries should call Arizona Complete Health-Complete Care Plan Member Services for benefit care coordination.
➢ Insulin Pumps ➢ Lab work and x-rays ➢ Medical foods for members diagnosed with one of the following inherited metabolic
conditions: o Phenylktonuria o Homocystinuria o Maple Syrup Urine Disease o Galactosemia (requires soy
formula) o Beta Keto-Thiolase Deficiency o Citrullinemia o Glutaric Acidemia Type I
o 3 Methylcrotonyl CoA Carboxylase
➢ Medical tests
Deficiency o Isovaleric Acidemia o Methylmalonic Acidemia o Propionic Acidemia o Arginosuccinic Acidemia o Tyrosinemia Type I o HMG CoA Lyase Deficiency o Cobalamin A, B, C Deficiencies
➢ Medically needed podiatry services. AHCCCS covers medically necessary podiatry services that are performed by a licensed podiatrist and ordered by a primary care provider or primary care practitioner.
➢ Medicine from the approved Arizona Complete Health-Complete Care Plan Drug List (Drug List)
➢ Nursing facility ➢ PCP office visits for children*, QMB, or when an adult has a symptom or sickness ➢ Pregnancy termination (including Mifepristone [Mifeprex or RU-486]) ➢ Post stabilization services ➢ Respiratory therapy ➢ Rides to health care visits ➢ Supplies and equipment, including Drug List diabetic testing equipment and supplies ➢ Well-child checkups including dental, hearing, shots and vision care*
DISEASE MANAGEMENT
Disease Management is a service offered at no cost to members who are receiving their health care through our integrated plan. If you have a health problem such as anxiety, chronic pain, diabetes, asthma, Chronic Obstructive Pulmonary Disease (COPD), heart failure or coronary artery disease, our Disease Managers are here to help you. Please call Member Services if you want to be referred for disease management assistance or for more information. If you are enrolled in DDD or CMDP, you can call your physical health plan for more information about managing your health.
ORTHOTICS CARE
Orthotic devices for members under the age of 21 are provided when prescribed by the member’s Primary �are Provider, attending physician, or practitioner.
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Arizona Complete Health-Complete Care Plan covers orthotic devices for members who are 21 years of age and older when:
➢ The orthotic is medically necessary as the preferred treatment based on Medicare Guidelines AND
➢ The orthotic costs less than all other treatments and surgery procedures to treat the same condition AND
➢ The orthotic is ordered by a Physician (doctor) or Primary Care Practitioner (nurse practitioner or physician assistant).
If you have any questions, please call Member Services at 1-888-788-4408 or TTY/TDD: 711.
Medical equipment may be rented or purchased only if other sources, which provide the items at no cost, are not available. The total cost of the rental must not exceed the purchase price of the item. Reasonable repairs or adjustments of purchased equipment are covered for all members over and under the age of 21 to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit. The component will be replaced if at the time authorization is sought documentation is provided to establish that the component is not operating effectively.
ADDITIONAL MEDICAL COVERED SERVICES FOR MEDICAID-ENROLLED YOUTH UNDER THE AGE OF 21
These services are also available to members that are under 21 years of age and are enrolled in
Medicaid:
• Identification, evaluation and rehabilitation of hearing loss
• Medically necessary personal care. This may include help with bathing, toileting, dressing, walking and other activities that the member is unable to do for medical reasons
• Routine preventive dental services, including oral health screenings, cleanings, oral hygiene education, X-rays, fillings, extractions and other therapeutic and medically necessary procedures
• Vision services, including exams and prescriptive lenses (a limited selection of lenses and frames are covered)
• Outpatient speech, occupational and physical therapy
• Conscious sedation
• Additional Services for Qualified Medicare Beneficiaries (QMB)
• Respite services
• Chiropractic services
• Any services covered by Medicare but not by AHCCCS.
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�overed �ehavioral Health ServicesAll Medicaid members enrolled with Arizona Complete Health-Complete Care Plan are eligible to receive the following AHCCCS funded behavioral health services. Call Member Services or talk to your PCP and/or Health Home for more information about these services:
➢ Case management services ➢ Behavior management (home care training, behavioral health self-help/ peer support) ➢ Psychotropic medications ➢ Psychotropic medication adjustment and monitoring ➢ Behavioral health nursing services ➢ Emergency or crisis services ➢ Emergency and non-emergency medically necessary transportation ➢ Screening, evaluation and assessment ➢ Individual, group and family counseling and therapy ➢ Inpatient hospital services ➢ Institute for mental disease (limited) ➢ Laboratory, radiology and medical imaging services for psychotropic medication
regulation and diagnosis ➢ Opioid Agonist treatment ➢ Inpatient behavioral health facility services ➢ Substance use (opioid, drug & alcohol) counseling ➢ Respite care (with limitations) ➢ Behavioral health supportive home care services ➢ Partial Care (supervised day program, therapeutic day program and medical day
program) ➢ Psychosocial rehabilitation (living skills training, health promotion; supportive
employment services)
Table of �ehavioral Health �overed Services
Available Behavioral Health Services
SERVICES TITLE 19/21 CHILDREN AND ADULTS
TREATMENT SERVICES
Individual Available
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SERVICES
Behavioral Health Counseling and Therapy
Group Available
Family Available
Behavioral Health Screening, Mental Health Assessment and Specialized
Testing
Behavioral Health Screening
Available
Mental Health Assessment
Available
Specialized Testing Available
Other Professional Traditional Healing
Provided based on available federal grant funding
Auricular Acupuncture Provided based on available federal grant funding
Intensive Outpatient Available
Multisystemic Therapy for Juveniles
Available
REHABILITATION SERVICES
Skills Training and Development; Psychosocial Rehabilitation
Individual Available
Group Available
Cognitive Rehabilitation Available
Behavioral Health Prevention/Promotion Education
Available
Psycho Educational Services and Ongoing Support to Maintain Employment
Available
BEHAVIORAL HEALTH MEDICAL SERVICES
Behavioral Health Medication Services Available
Behavioral Health Lab, Radiology, and Medical Imaging
Available
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Behavioral Health Counseling and Therapy
Behavioral Health Screening, Mental Health Assessment and Specialized
Testing Behavioral Health Screening, Mental Health Assessment and Specialized
Testing
Other Professional
Other Professional
Other Professional
Skills Training and Development; Psychosocial Rehabilitation
Cognitive Rehabilitation
REHABILITATION SERVICES
Behavioral Health Related Medical Management
Available
Electro-Convulsive Therapy Available
SUPPORT SERVICES
Case Management Available
Personal Care Available
Home Care Training (Family) Available
Self-Help/Peer Services Available
Home Care Training to Home Care Client (HCTC)
Available
Respite Care (Reference Limitations Section for details about coverage limits)
Available
Supported Housing Provided based on available state and federal grant funding
Sign Language or Oral Interpretive Services
Provided at no charge to the member
Emergency Behavioral Health Transportation
Available
Non-emergency Behavioral Health Transportation
Available
Crisis Intervention – Mobile Community Based
Available
Crisis Intervention – Telephone Available
Crisis Services – up to 23 Hour Stabilization, Facility Based
Available
INPATIENT SERVICES
Behavioral Health Detox Inpatient Facility (Substance Use Disorders)
Available
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Behavioral Health Inpatient Facility (Mental Health Disorders)
Available
RESIDENTIAL SERVICES
Behavioral Health Residential Facility (Mental Health Treatment)
Available
Behavioral Health Residential Facility (Substance Use Disorder Treatment)
Available
Room and Board Provided based on available state and federal grant funding
BEHAVIORAL HEALTH DAY PROGRAMS
Supervised Day Program Available
Therapeutic Day Program Available
Medical Day Program Available
Non-�overed Services: What does !H���S Not �over?
➢ Non-emergency physical health services that are not prior approved by your PCP. ➢ Any care, treatment, or surgery that is not medically necessary. ➢ Infertility services that include testing and treatment. ➢ Reversals of elective sterilization. ➢ Gender affirming operations. ➢ Exams to establish the need for hearing aids, glasses, or contacts for members 21 years
and older, except after cataract surgery. ➢ Hearing aids, eye glasses, or contacts for members 21 years and older, except after
cataract surgery. ➢ Services or items for cosmetic reasons. ➢ Personal or comfort items (only covered for EPSDT, if medically indicated). ➢ Non-prescription drugs or supplies ➢ Services given in an institution for the treatment of tuberculosis (TB). ➢ Medical service given to an inmate or to a person in the custody of a state mental health
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institution. ➢ Lower limb microprocessor controlled joint/prosthetic for members 21 years of age and
older. ➢ Any service determined as experimental/investigational or done mainly for research or
that has not been approved by regulating agencies. AHCCCS members who are enrolled with a plan may participate in experimental treatment, but AHCCCS will not reimburse for the experimental treatment.
➢ Transplants including: Pancreas only transplants (total, partial or islet cell); or any other transplant not listed by AHCCCS as covered.
➢ Physical exam for non-medical purposes (for example, job, school or insurance exams). ➢ Abortion counseling and abortions (unless medically necessary per AHCCCS medical
policies). ➢ Any medical services outside of the country. ➢ Routine/newborn circumcisions. ➢ Routine health care (out-of-area).
Exclusions and Limitations Table
The following services are not covered or are limited services for adults 21 years and older. If you are a Qualified Medicare Beneficiary (QMB), we will continue to pay your Medicare deductible and coinsurance for these services.
BENEFIT/SERVICE SERVICE DESCRIPTION SERVICE EXCLUDED FROM PAYMENT
Bone-Anchored Hearing Aid
A hearing aid that is put on a person’s bone near the ear by surgery. This is to carry sound.
AHCCCS will not pay for the Bone-Anchored Hearing AID (BAHA). Supplies, equipment maintenance (care of the hearing aid) and repair of any parts will be paid for.
Cochlear Implant
A small device that is put in a person’s ear by surgery to help you hear better.
AHCCCS will not pay for cochlear implants. Supplies, equipment maintenance (care of the implant) and repair of any parts will be paid for.
Lower limb Microprocessor controlled joint/
Prosthetic
A device that replaces a missing part of the body and uses a computer to help with the moving of the joint.
AHCCCS will not pay for a lower limb (leg, knee, or foot) prosthetic that includes a microprocessor (computer chip) that controls the joint.
Orthotics
A support or brace for weak joints or muscles. An orthotic can also support a deformed part of the body.
Arizona Complete Health-Complete
Care Plan covers orthotic devices for
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Orthotics means items like leg braces, wrist splints and neck braces.
members who are 21 years of age
and older when:
➢ The orthotic is medically necessary as the preferred treatment based on Medicare Guidelines AND
➢ The orthotic costs less than all other treatments and surgery procedures to treat the same condition AND
➢ The orthotic is ordered by a Physician (doctor) or Primary Care Practitioner (nurse practitioner or physician assistant).
Respite Care
Short-term or continuous services provided as a temporary break for caregivers and members to take time for themselves.
The number of respite hours available to adults and children under ALTCS benefits or behavioral health services is being reduced from 720 hours to 600 hours within a 12 month period of time. The 12 months will run from October 1 to September 30 of the next year.
Services by Podiatrist
Any service that is done by a doctor who treats feet and ankle problems.
AHCCCS covers medically necessary podiatry services that are performed by a licensed podiatrist and ordered by a primary care provider or primary care practitioner.
Transplants
A transplant is when an organ or cells are moved from one person to another.
Approval is based on the medical need and if the transplant is on the “covered” list/ Only transplants listed by AHCCCS as covered will be paid for.
Physical Therapy and Occupational
Therapy
Exercises taught or provided by a Physical Therapist to make you stronger or help improve movement.
Outpatient physical therapy visits to restore a level of function are limited to 30 visits per contract year (October 1 to September 30 of the following year).
Members who have Medicare should talk to the health plan for help in determining how the visits will be counted.
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Arizona Complete Health-Complete Care Plan will not be responsible for payment for any non-covered services you choose to receive. In special cases you may be able to get services outside of your service area. Please contact Member Services if you would like more information about this.
�onsent to Treatment
You have the right to accept or refuse behavioral health services that are offered to you. If you
want to get the behavioral health services offered, you or your legal guardian must sign a
“�onsent to Treatment” form giving your or your legal guardian’s permission for you to get
behavioral health services/ When you sign a “�onsent to Treatment” form, you are also giving
the Arizona Health Care Cost Containment System (AHCCCS) permission to access your records.
To give you certain services, your provider needs to get your permission. Your provider may ask
you to sign a form or to give verbal permission to get a specific service. You will be given
information about the service so you can decide if you want that service or not. This is called
informed consent. Informed consent means advising a patient of a proposed treatment,
surgical procedure, psychotropic drug, or diagnostic procedure; alternatives to the treatment
surgical procedure, psychotropic drug or diagnostic procedure; associated risks and possible
complications, and obtaining documented authorization for the proposed treatment, surgical
procedure, psychotropic drug, or diagnostic procedure from the patient or the patient’s
representative. An example would be if your provider prescribes a medication. Your provider
will tell you about the benefits and risks of taking the medication and other options for
treatment. Your provider will ask you to sign a consent form or give verbal permission if you
want to take the medication. Let your provider know if you have questions or do not
understand the information your provider gave you. You have the right to withdraw your
consent at any time. Your provider will explain to you what will happen if you choose to
withdraw your consent.
ACCESSING NON-TITLE 19/21 SERVICES COORDINATED THROUGH THE REGIONAL BEHAVIORAL HEALTH AUTHORITY (RBHA)
Some services coordinated through the Regional Behavioral Health Authority are available to
members who are not eligible for Medicaid (Non-Title 19/21). Grant-funded programs include
activities to prevent and treat Substance Use Disorders and Opioid Use Disorders, to provide
early intervention services for HIV and tuberculosis disease, and to provide mental health
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services to adults with Serious Mental Illness (SMI) and children with Serious Emotional
Disturbance (SED).
You can find out more about these programs by visiting our website or calling Member Services
at 888-788-4408 TTY/TDY 711.
HOUSING SERVICES
Supportive Housing is a service available for Arizona Complete Health-Complete Care Plan
members which helps individuals secure safe and stable housing to live independently in the
community of their choice. Regional Behavioral Health Authorities contract with Provider
Agencies/Organizations which offer housing services consistent with Substance Abuse and
Mental Health Services Administration (SAMHSA's) Evidenced Based Practice of permanent
supportive housing. Regional Behavioral Health Authorities collaborates with system partners
such as the US Department of Housing & Urban Development, Arizona Department of Housing,
local Housing Authorities and local Housing Continuum of Care Committees. The numbers of
members that can be assisted with housing in any given year depends upon the funding level
awarded by the State each year for this purpose. If you are interested in learning more about
housing supports and services please call Arizona Complete Health-Complete Care Plan
member Services at 888-788-4408 TTY/TDY 711.
PEER AND FAMILY SUPPORT RESOURCES
Peer Support Services and Family Support Services are behavioral health services available to
our members. Peer Run Organizations are owned, managed, and staffed by people who have
received mental health services. These organizations can provide a wide range of services to
adult members, including peer support, living skills, vocational skills, re-entry support (support
when coming out of prison), veterans’ services, and entrepreneurship skills/ Peer support
services are provided by individuals who have shared similar life experience, they understand
what you’re going through/ Family Run Organizations are governed by family members of
children with mental health challenges. These organizations service families with children with
behavioral, emotional and mental health challenges. They can provide services including family
support, respite services, wellness and living skills, youth support, and vocational skills to
families of children receiving behavioral health services. Call Member Services to find out more.
END OF LIFE CARE/ ADVANCE CARE PLANNING
➢ End-of-life care is health care including physical, psychosocial and spiritual support provided to members that are facing a decline in their health status or have been diagnosed with a complex, chronic or terminal illness. The goal of end-of-life care is to improve member quality of life by providing services such as: ➢ Physical and/or behavioral health treatments to relieve pain and other
unpleasant symptoms brought on by the member’s illness/
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➢ Referrals for community resources including but not limited to pastoral care, counseling and legal services.
➢ Practical supports: non-billable services provided by a family member, friend or volunteer to assist with activities of daily living and other non-medical comfort measures.
➢ End-of-life care includes advance care planning, which are in-person conversations between members and their health care providers about their illness and treatment choices. Advance care planning allows members to fully understand the expected progression of their illness and their treatment options. It provides members with the opportunity to decide with their health care providers and their families or involved caregivers what their treatment course will be when faced with life limiting illness regardless of age or the stage of the illness. Once begun, advance care planning should be an ongoing process that continues throughout the duration of a member’s life/
➢ End-of-Life care allows members to receive palliative care, supportive care, and hospice services and often includes the development of advance directives, a legal document stating a person’s health care preferences in event that they are not able to make their own health care decisions/ These services are obtained through a member’s physician or other qualified health care provider, such as a nurse practitioner or a physician’s assistant.
If you would like more information about End of Life Care for you or a loved one, please call
member services at 1-888-788-4408 (TTY/TDY: 711).
Specialty Services and Referrals A referral is when your Arizona Complete Health-Complete Care Plan Care Manager, PCP or
Behavioral Health Home sends you to a specialist for a specific service. Your Care Manager, PCP
or Behavioral Health Home may want you to see a specialist or get special services. You may
contact Arizona Complete Health-Complete Care Plan, Behavioral Health Home or your PCP if
you feel you need a referral for specialized care. A referral can be to a specialty provider, lab or
hospital. Your PCP or Behavioral Health Home will arrange for the specialty services listed
below. Some of these specialty services may require Prior Authorization.
➢ Nutritional Assessments for members 21 years of age and older.
➢ Home health visits
➢ Organ transplants
➢ Skilled nursing home care
➢ Rehabilitation services like physical therapy, occupational therapy, or speech
therapy
➢ Specialist care
➢ Surgery
➢ Certain x-rays, scans or medical tests
➢ Durable Medical Equipment such as wheelchairs or oxygen
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You do not need a referral for the following specialty services:
➢ Emergency Services; including non-contracted out-of-network Emergency Departments ➢ Urgent Care Services ➢ Most behavioral health outpatient services (see Behavioral Health Services section for
more information) ➢ OB/GYN services, and ➢ Dental services for children under the age of 21.
Please note: Individuals can have a Pap smear or mammogram screening (after age 40 and at
any age if considered medically necessary) once a year without a referral from their PCP. Please
contact Member Services for more information on Pap smears and colonoscopies.
We may need to review and approve certain referrals and special services before you can get
the services. Some medical services and specialists need our prior approval. If they do, your
Care Manager, PCP or Behavioral Health Home will arrange for a Prior Authorization for these
services. We must review these requests. Your Arizona Complete Health-Complete Care Plan
Care Manager, PCP, Specialty Provider or Behavioral Health Home’s office will let you know if
your Prior Authorization request is approved. You can also call Member Services to find out the
status of your request.
IN-NETWORK REFERRALS AND FREEDOM OF CHOICE OF PROVIDERS
You are required to use an Arizona Complete Health-Complete Care Plan in-network specialty
provider. You can find Arizona Complete Health-Complete Care Plan contracted in-network
specialty providers on our website at www.azcompletehealth.com/completecare. Arizona
Complete Health-Complete Care Plan offers members the freedom of choice in selecting
doctors and specialists in our network.
DENIAL OF REQUESTS FOR SPECIALTY SERVICES
If your specialty provider request is denied, we will let you know by mail. Our letter will also tell
you how to appeal our decision if you are not happy with the decision. If you have a question
about the denial, you may call Member Services at 1-888-788-4408 (TTY/TDY: 711). For more
information about filing an appeal for a denied authorization, please see the section titled
“Complaints: What Should I Do if I !m Unhappy?” in this handbook.
You have the right to get services from a provider whose religious or moral character you do
not object to. If you object to the religious or moral character of your provider, you may ask for
a referral to another provider. You will get an appointment with the new provider within 7 days
of your request for a referral, or earlier if needed. The new provider must be available to you
and provide services that are similar to the services that you were receiving at the first
provider.
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If you are having trouble accessing services due to the moral or religious objections of a
provider, please call Member Services at 1-888-788-4408 (TTY/TDY: 711) for assistance with
finding a provider that can meet your needs.
MEMBERS WHO ARE AMERICAN INDIAN
American Indian members are able to receive health care services from any Indian Health
Service provider or tribally owned and/or operated facility at any time.
Your Primary �are Provider (P�P) Your Primary Care Provider (PCP) or Behavioral Health Home facilitates your access to services. Your PCP or Behavioral Health Home may provide you medical services or your PCP or Behavioral Health Home may make plans for you to get these services from another provider (sometimes called a specialist). You should always contact your PCP or Behavioral Health Home before you see any other provider or attempt to get outside services.
You do not have to see your PCP or Behavioral Health Home for the following: ➢ Emergency Services ➢ Urgent Care Services ➢ Crisis Services ➢ Behavioral Health Services ➢ Substance Use Disorder Services ➢ OB/GYN services ➢ Dental services
Please note:
➢ Members can have a pap smear or mammogram screening (after age 40 and at any age if considered medically necessary) once a year without a referral from their PCP. Please contact Member Services for more information on Pap smears and colonoscopies.
HOW TO CHOOSE OR CHANGE A PRIMARY CARE PROVIDER (PCP)
It is important that you choose a PCP who makes you feel comfortable. When you have a PCP
that you like, your PCP will be able to better help you with your health care. This relationship is
very important in providing you the care you need. You can find a list of our doctors on our
website at www.azcompletehealth.com/completecare or by calling Member Services at 1-888-
788-4408, TTY/TDY 711.
If you wish to change your PCP, please call Member Services for assistance. A PCP change can be made effective the same date of the request. However, we encourage you not to change your PCP more than twice a year.
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HOW CAN DOCTOR VISITS HELP YOU STAY HEALTHY?
➢ Make sure children under the age of 21 receive their annual well-exams 1and immunizations.
➢ Adults ages 21 and older should receive their annual well-exams and should visit their PCP when a symptom or sickness develops or for regular care of a chronic condition.
➢ Schedule preventative exams such as Pap smear, Mammogram (after age 40 and at any age if considered medically necessary) and Cancer screening once a year. Talk to your doctor about other important screening and preventative tests, such as colonoscopies, prostate exams, diabetes tests, cholesterol tests.
➢ Keep your appointment for tests that your doctor has ordered for you. ➢ Know why it is important for you to have the test done and what could happen if you don’t have it done/
➢ Ask your doctor to help you learn how to take better care of yourself.
HOW TO MAKE, CHANGE, OR CANCEL AN APPOINTMENT
How to Make an Appointment:
➢ Call your PCP, dentist, or specialist to schedule your appointment ➢ Tell the provider’s office. your name, your !H���S Identification (ID) number (this
appears on the front of your Arizona Complete Health-Complete Care Plan ID card), your doctor’s name, and why you need to see this doctor/
How to Change an Appointment:
➢ �all your doctor’s office at least 24 hours ahead of time ➢ Tell the doctor’s office. your name, your !H���S ID number, the date of your
appointment, and ask to set a new date to see your doctor.
How to Cancel your Appointment:
➢ �all your doctor’s office 24 hours ahead of time. ➢ Tell the doctor’s office that you want to cancel your appointment and provide them
with: your name, your AHCCCS ID number, and the date of your appointment. ➢ If already arranged, call Member Services to cancel transportation or interpreter
services when no longer needed.
If you are unable to contact your doctor’s office and need help, please call Arizona Complete Health-Complete Care Plan Member Services.
1 *A well-child visit/check is the same as an Early Periodic Screening, Diagnostic and Treatment (EPSDT) visit.
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!ppointment availability – How long should it take to see a provider
When you call your provider to set up an appointment or get a referral for an appointment you
should expect to see that provider within the timelines below:
• PCP Urgent: 2 business days • PCP Routine: 21 calendar days • Specialist Urgent: 3 business days • Specialist Routine: 45 calendar days • Dental Urgent: 3 business days • Dental Routine: 45 calendar days • Maternity Care 1st Trimester: 14 calendar days • Maternity Care 2nd Trimester: 7 calendar days • Maternity Care 3rd Trimester: 3 business days • Maternity Care Risk: as required based on needs but no later than 3 business days • Behavioral Health Urgent Need: 24 hours • Behavioral Health Routine Initial Assessment: 7 calendar days • Behavioral Health Routine First Service: 23 calendar days • Behavioral Health Routine Subsequent Service: with time frames according to needs
but no later than 45 days • Referrals for Psychotropic Meds: in accordance to urgency of need but no later than 30
calendar days • Rapid Response: 72 hours • Rapid Response Initial Assessment: 7 calendar days • Rapid Response Initial Appointment: 21 calendar days • Rapid Response Subsequent Services: 21 calendar days
WELL VISITS
Well visits (well exams) such as, but not limited to, annual exams, breast exams, and prostate
exams are covered for members 21 years of age and older. Most well visits (also called checkup
or physical) include a medical history, physical exam, health screenings, health counseling and
medically necessary immunizations. (See EPSDT for well exams for members under 21 years of
age)
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WELL-CHILD CARE / EARLY PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT)*
Early Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health
program of prevention and treatment, correction, and improvement (amelioration) of physical
and mental health problems for AHCCCS members under the age of 21.
The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as
well as to assist Medicaid recipients in effectively utilizing these resources.
EPSDT services provide comprehensive health care through primary prevention, early
intervention, diagnosis, medically necessary treatment, and follow-up care of physical and
behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services
include screening services, vision services, dental services, hearing services and all other
medically necessary mandatory and optional services listed in federal law 42 U.S.C. 1396d(a) to
correct or ameliorate defects and physical and mental illnesses and conditions identified in an
EPSDT screening whether or not the services are covered under the AHCCCS state plan.
Limitations and exclusions, other than the requirement for medical necessity and cost
effectiveness do not apply to EPSDT services.
A well child visit is synonymous with an EPSDT visit and includes all screenings and services
described in the AHCCCS EPSDT and dental periodicity schedules.
Amount, Duration and Scope: The Medicaid Act defines EPSDT services to include screening
services, vision services, dental services, hearing services and “such other necessary health
care, diagnostic services, treatment and other measures described in federal law subsection 42
U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services, whether or not such services are covered
under the (!H���S) state plan/”
This means that EPSDT covered services include services that correct or ameliorate physical and
mental defects, conditions, and illnesses discovered by the screening process when those
services fall within one of the 29 optional and mandatory categories of “medical assistance” as
defined in the Medicaid Act. Services covered under EPSDT include all 29 categories of services
in the federal law even when they are not listed as covered services in the AHCCCS state plan,
AHCCCS statutes, rules, or policies as long as the services are medically necessary and cost
effective.
EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services,
laboratory and x-ray services, physician services, nurse practitioner services, medications,
dental services, therapy services, behavioral health services, medical supplies, prosthetic
devices, eyeglasses, transportation, and family planning services. EPSDT also includes
diagnostic, screening, preventive and rehabilitative services. However, EPSDT services do not
44
include services that are solely for cosmetic purposes, or that are not cost effective when
compared to other interventions.
The Well-child* program includes the following procedures and tests to be performed as
recommended by AHCCCS or at any time if medically indicated:
➢ Medical history evaluation
➢ Height and weight measurements, including Body Mass Index (BMI) for those 24 months
and older
➢ Head circumference from birth to 24 months
➢ Blood pressure measurement - the need for blood pressure measurement for children
from birth to 24 months should be assessed by PCP
➢ Nutritional assessment
➢ Vision assessment
➢ Hearing and speech assessment
➢ Developmental/behavioral assessment
➢ Physical Examination
➢ Immunizations
➢ Tuberculin (Tuberculosis) test (for members at risk between the ages of 12 months
through age 20)
➢ Hematocrit/Hemoglobin testing
➢ Urinalysis testing
➢ Lead screening/Verbal testing
➢ Lead screening test and blood lead testing at ages 12 and 24 months and at 36 and 72
months if not previously tested
➢ Anticipatory guidance
➢ Dyslipidemia screening
➢ Dyslipidemia testing (one time testing between 18 and 20 years of age)
➢ STI Screening (risk assessment for those 11-20)
➢ Cervical Dysplasia Screening (risk assessment for those 11-20)
➢ Oral health assessments every 6 months.
➢ Fluoride varnish may be applied by the PCP during these visits beginning at 6 months of
age with at least one tooth, and may be repeated every 6 months until the age of two
years.
➢ Dental referral. First examination is encouraged to begin by age 1. Repeat dental visits
every 6 months or as indicated by child’s risk status or susceptibility to disease/ For
more information on dental care coverage, please see the “Dental Care” section in this
handbook.
Well-child care will also give you ideas about how to:
45
➢ Keep your child well
➢ Protect your child from getting hurt
➢ Spot health problems early
➢ !pply for services like WI�, Head Start, �hildren’s Rehabilitative Services (CRS), and the
Arizona Early Intervention Program (AzEIP)
All children should see their doctor for well-child* visits regularly. Well-child checkups should
be done at the following ages or at any other time if medically indicated:
➢ Newborn
➢ 3-5 days old
➢ 1 month
➢ 2 months old
➢ 4 months old
➢ 6 months old
➢ 9 months old
➢ 12 months old
➢ 15 months old
➢ 18 months old
➢ 24 months old
➢ Annually from 3 through 20 years old
We will send you a reminder about well-child checkups. Make an appointment with your PCP. It
is important for your child to go to all the well-child checkups.
*A well-child visit/check is the same as an EPSDT.
PREVENTATIVE AND WELL CARE
Female Members have direct access to preventive and well care services from a gynecologist
within the �ontractor’s network without a referral from a primary care provider/ Please contact
Member Services for more information on Pap smears (a test for Cervical Cancer),
mammograms (a test for Breast Cancer), and colonoscopies.
Our members can go directly to a network obstetrics/gynecology doctor for preventive and
routine health care services. No referral is needed from your PCP.
Family Planning46
Family Planning services are available to members of any gender who are of reproductive age.
Family Planning will help you decide when to have children. Our providers can help you choose
birth control methods that will work for you. Family Planning services require no copayment
and are offered at no cost to you. You may seek family planning services from any network PCP
or Gynecologist. No referral is needed from your PCP.
The following birth control methods are provided at no cost to you:
➢ Birth Control Counseling
➢ Birth control pills or Long Acting Reversible contraceptives (LARC), condoms, diaphragms,
foams and suppositories
➢ Natural family planning and referral to qualified health professionals
➢ Post-coital emergency contraception (also known as the morning after pill)
➢ Sterilization only for members 21 years of age or older
Please note: That this is not an all-inclusive list of covered birth control methods.
The following services are not covered under Family Planning:
➢ Infertility services including testing, treatment, or reversal of a tubal sterilization or
vasectomy
➢ Pregnancy termination counseling
➢ Pregnancy termination – unless you meet the conditions described in the “Medically
Necessary Pregnancy Termination” section above/
➢ Hysterectomies if done for family planning only
We also want you to be able to get medical care if you lose your AHCCCS eligibility. This
handbook contains a list of clinics that offer low cost or free medical care. Call the clinics to find
out about services and costs. If you have questions or need help call Arizona Complete Health-
Complete Care Plan Member Services at 1-888-788-4408, TTY/TDY 711.
If you lose eligibility for AHCCCS services, Arizona Complete Health-Complete Care Plan can
help you find low-cost or no-cost family planning services, or you may call the Arizona
Department of Health Services Hotline at 1-800-833-4642.
MATERNITY CARE
When you become pregnant, we want you to have a healthy pregnancy and a healthy baby. We
have special programs that can help you throughout your pregnancy and after your baby’s
birth, and even can provide incentives for you to attend your appointments. If you find out that
47
you are pregnant, please give us a call so we can tell you more about what we can offer and
how we can work with you to have the best outcomes for your pregnancy. Please call Member
Services at the numbers below. Maternity care includes identification of pregnancy prenatal
care, labor and delivery services and postpartum care. It is important that you make and keep
appointments with your doctor during your pregnancy. If you need help making an
appointment, please call Member Services at 1-888-788-4408, TTY/TDY 711.
Maternity care coordination consists of the following maternity care related activities:
determining the member's medical or social needs through a risk assessment evaluation;
developing a plan of care designed to address those needs; coordinating referrals of the
member to appropriate service providers and community resources; monitoring referrals to
ensure the services are received; and revising the plan of care, as appropriate.
Preconception counseling services, as part of an annual visit, are provided when medically
necessary. This counseling focuses on the early detection and management of risk factors
before pregnancy, and includes efforts to influence behaviors that can affect a fetus (even
before conception is confirmed), as well as regular health care. The purpose of preconception
counseling is to ensure that an individual is healthy prior to pregnancy. Preconception
counseling does not include genetic testing.
PREGNANCY IDENTIFICATION
As soon as you think you are pregnant, call your PCP to get a pregnancy test. Once you know
that you are pregnant, it is important to choose a prenatal care provider. Please note: Your
prenatal care provider may also serve as your Primary Care Provider. Call Member Services to
choose a prenatal care provider that is right for you. Then call the provider to make your first
appointment. You will not need a referral to see a prenatal care provider. There are different
types of prenatal care providers that you can choose from. You may choose a doctor that
specializes in pregnancy (also known as Obstetrician), a Certified Nurse Midwife, a licensed
midwife (if you are over the age of 18 and are not high risk), a nurse practitioner or a
physician’s assistant/
PRENATAL CARE
Prenatal care is the health care provided during pregnancy and is composed of three major
components:
1. Early and continuous risk assessment
2. Health education and promotion, and
3. Medical monitoring, intervention, and follow-up.
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Call and get your appointment as soon as you know you are pregnant. Please note: It is very
important to go to all of your prenatal appointments as scheduled by your provider. During
your prenatal care visits your provider may give this care:
➢ �heckups (including blood pressure check, check your weight, check your baby’s
movement and growth, and listen to your baby’s heartbeat)
➢ Tests you may need, such as blood tests and urine tests to check that you are well.
➢ Check for infections, including sexually transmitted infections and HIV/AIDS. NOTE:
Voluntary prenatal HIV testing and counseling is available to members.
➢ Give you prescriptions for prenatal vitamins or other medications the doctor prescribes.
When you find out you are pregnant, your provider must see you within:
➢ Fourteen (14) days if you are in your first trimester
➢ Seven (7) days if you are in your second trimester
➢ Three (3) days if you are in your third trimester
➢ Three (3) days if your pregnancy is high-risk or immediately if it is an emergency.
If you are not able to get an appointment within these time frames, call Member Services to
assist you with getting a timely appointment. Call Member Services if you need a ride to your
prenatal care appointments.
During your prenatal care visits, your provider will talk to you about staying healthy during your
pregnancy. Your provider may talk about:
➢ Eating healthy foods
➢ Exercise during pregnancy
➢ Not smoking, not drinking alcohol or using other drugs during pregnancy.
➢ The normal pregnancy changes your body will go through
➢ When to call your provider right away for health changes.
At your first visit, your provider will also do a risk assessment to identify your medical,
behavioral or social needs. Your questions and needs will show the doctor how a pregnancy will
be set. At this time, your doctor will make referrals to community service offices and resources
can be coordinated. Some examples of community service offices are Women, Infants and
Children (WIC) and other state assistance programs like the Department of Economic Security
(DES). DES provides financial aid to Arizona residents that qualify at application. Your pregnancy
care plan may be changed as needed. If you need help during your pregnancy, call Member
Services and we can help. Arizona Complete Health-Complete Care Plan has care managers to
assist our providers with maternity care coordination. You can change providers or plans during
your pregnancy. If you need help, the care managers can help you. Call Member Services if you
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need help for any of these reasons.
HIGH RISK PREGNANCY
High-risk pregnancy refers to a pregnancy in which the child-bearer, fetus, or newborn is, or is
anticipated to be, at increased risk for morbidity or mortality before or after delivery. High-risk
is determined through the use of the Medical Insurance Company of Arizona (MICA) or
American College of Obstetricians and Gynecologists (ACOG) standardized medical risk
assessment tools. These forms are completed by your OB physician during your visit with them
Your pregnancy may be high-risk if you or your baby have a medical or other condition that
could make you or your baby sick while you are pregnant or after delivery.
Arizona Complete Health-Complete Care Plan has care managers that can help you with your
high risk pregnancy at no cost to you. Our care managers can answer your questions and help
you with your appointments or referrals. If you want to talk to one of our care managers,
please call Member Services at 1-888-788-4408, TTY/TDY 711.
LABOR AND DELIVERY CARE
When your baby is due (pregnancy usually is 40 weeks until delivery), your provider will deliver
your baby at a hospital or birthing center. The hospitals are listed in the Provider Directory. If
your pregnancy is not high risk, you may be able to deliver your baby at home with a licensed
physician, practitioner or licensed midwife.
➢ Practitioner refers to certified nurse practitioners in midwifery, physician's assistants
and other nurse practitioners.
➢ A Licensed Midwife is an individual licensed by the Arizona Department of Health
Services to provide maternity care pursuant to Arizona Revised Statutes (A.R.S.) Title 36,
Chapter 6, Article 7 and Arizona Administrative Code Title 9, Chapter 16. (This provider
type does not include Certified Nurse Midwives licensed by the Board of Nursing as a
nurse practitioner in midwifery or physician assistants licensed by the Arizona Medical
Board.)
➢ A Certified Nurse Midwife (CNM) is certified by the American College of Nursing
Midwives (ACNM) on the basis of a national certification examination and licensed to
practice in Arizona by the State Board of Nursing. CNMs practice independent
management of care for pregnant individuals and newborns, providing antepartum,
intrapartum, postpartum, gynecological, and newborn care, within a health care system
that provides for medical consultation, collaborative management, or referral.
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POSTPARTUM CARE
Postpartum care is the health care provided for a period of up to 60 days post-delivery. This is
called a postpartum visit. This final part of maternity care is very important and should not be
avoided even if your delivery went well. Your provider will examine you for medical and
behavioral health needs after your baby was born. Many individuals that have given birth can
feel sad or depressed after their baby is born. Tell your provider if you have these feelings.
Depression can be treated. It is important to let someone know if you are feeling depressed.
Family planning services are included if provided by a physician or a practitioner. Call Member
Services to schedule an appointment or if you need a ride to your postpartum care
appointments.
HIV/AIDS TESTING
Voluntary, confidential HIV/AIDS testing services are available to members (including prenatal
members), as well as counseling for members who test positive. Arizona Complete Health-
Complete Care Plan can help. Call Arizona Complete Health-Complete Care Plan Member
Services at 1-888-788-4408, TTY/TDY 711, for information about confidential testing or
counseling services.
Important Note: Family Planning services are available to members of any gender who are of
reproductive age. You may seek family planning services from any network PCP or
Gynecologist. No referral is needed from your PCP.
MEDICALLY NECESSARY PREGNANCY TERMINATIONS
Pregnancy terminations are an AHCCCS covered service only in special situations. AHCCCS covers
pregnancy termination if one of the following criteria is present:
1. The pregnant member suffers from a physical disorder, physical injury, or physical illness
including a life-endangering physical condition caused by, or arising from, the pregnancy
itself that would, as certified by a physician, place the member in danger of death,
unless the pregnancy is terminated.
2. The pregnancy is a result of incest.
3. The pregnancy is a result of rape.
4. The pregnancy termination is medically necessary according to the medical judgment of
a licensed physician, who attests that continuation of the pregnancy could reasonably
be expected to pose a serious physical or behavioral health problem for the pregnant
member by:
a. Creating a serious physical or behavioral health problem for the pregnant member,
b. Seriously impairing a bodily function of the pregnant member,
c. Causing dysfunction of a bodily organ or part of the pregnant member,
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d. Exacerbating a health problem of the pregnant member, or
e. Preventing the pregnant member from obtaining treatment for a health problem.
Dental �are
MEMBERS UNDER 21 YEARS OF AGE
All dental health checkups, cleanings and treatments are covered for members under the age of
21. A doctor referral is not needed to see a dentist. Two (2) routine and preventive dental visits
are covered per year for members under the age of 21. It is important to take your children to
the dentist twice a year to keep their teeth healthy. From the time the first tooth appears,
children should visit their dentist for a checkup every six months.
Every member under age 21 needs to have a Dental Home. A Dental Home is an assigned
dentist who will get you or your child the dental care that is needed. Call Member Services to
select a dentist or one will be assigned. If a dentist is assigned that you do not want, or if you
see a dentist already in our network and you are happy with that dentist please call Member
Services at 1-888-788-4408 or TTY/TDY 711 to ask to keep that dentist.
Arizona Complete Health-Complete Care Plan sends dental checkup reminder letters to
members. It is important to go to your scheduled visit because dentists can help prevent
cavities. They can use dental sealants (a plastic coating painted on the back teeth) and fluoride
treatments. Dentists also teach you and your child how to care for teeth. It is important to visit
the dentist for checkups two times every year. Call Member Services if you need help finding a
dental provider. Once you choose a dentist, you can call their office to make or change an
appointment.
The following routine dental services are only covered for members under the age of 21:
➢ Dental exams
➢ Dental cleanings
➢ Fillings for cavities
➢ X-rays to screen for dental problems
➢ Application of fluoride
➢ Dental sealants
➢ Emergency dental services
Use these guidelines for scheduling appointments for your child:
➢ Emergency dental appointments – ask for a same-day appointment for extreme pain and
dental emergencies.
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➢ Urgent dental appointments – within 3 days for lost fillings, broken tooth.
➢ Routine dental appointments – within 45 days, for routine checkups and dental
cleanings.
➢ Make sure you take your child’s Arizona Complete Health-Complete Care Plan ID card
with you to the dental appointment.
If you need to make, change, or cancel a dental appointment please contact your dentist or
Arizona Complete Health-Complete Care Plan Member Service 1-888-788-4408 or TTY/TDY 711
for assistance.
MEMBERS 21 YEARS OF AGE AND OLDER
What if I am over 21 years old and have a dental emergency? Limited dental services are
covered to relieve severe pain and or infection. Adult members 21 years of age and older can
receive emergency dental services, limited to $1000 member per contract year. Emergency
services over the $1000 benefit are the responsibility of the member.
Routine dental services are not covered for members 21 years of age or older. AHCCCS covers
medical and surgical services related to dental (oral) care only to the extent such services may
be performed under State law by either a physician or by a dentist and the services would be
considered physician services if done by a physician. Covered dental services for members 21
years of age and older must be related to the treatment of a medical condition such as loss of
tooth/teeth due to trauma, cyst or tumor, or fracture of the jaw. Covered dental services
include examining the mouth, x-rays, care of fractures of the jaw or mouth, giving anesthesia,
and pain medication and/ or antibiotics.
What else is covered? Certain pre-transplant services related to the elimination of oral
infections and treatment of oral disease (such as dental cleanings, filings, simple restorations,
extractions) and prophylactic extraction of teeth in preparation for radiation treatment of
cancer of the jaw, neck or head are also covered. These services are not part of the $1000 adult
emergency dental limit.
Pharmacy Services Our pharmacy program includes high-quality, cost-effective medication therapy. We work with
providers and pharmacists to ensure that we cover medications used to treat a variety of
conditions and diseases. When ordered by a provider, we cover prescription medications and
certain over-the-counter medications.
Some medications require prior authorization or have limitations on age, dosage and maximum
quantities. For some drugs, you must try another drug first – this is called step therapy. Please
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refer to the Arizona Complete Health-Complete Care Plan Preferred Drug List or PDL for more
detail. Arizona Complete Health-Complete Care Plan will cover the drugs listed on our
Preferred Drug List as long as they are medically necessary and appropriate. The Arizona
Complete Health-Complete Care Plan PDL includes all medications covered on the related
AHCCCS Preferred Drug List and include additional medications that are safe and effective.
The Arizona Complete Health-Complete Care Plan PDL can be found at
www.azcompletehealth.com/completecare
WHAT IF A DRUG IS NOT ON THE PDL/FORMULARY?
The PDL is not a complete list of drugs covered by Arizona Complete Health-Complete Care
Plan. If the medicine your doctor feels you need is not on our list of covered drugs and you
can’t take any other medication except the one prescribed, your doctor may request Prior
Authorization from us.
Arizona Complete Health-Complete Care Plan will approve your request for an exception if the
alternative drugs included on the formulary or additional restrictions would not be as effective
in treating your condition and/or would cause you to have adverse medical effects.
WHAT IF MY REQUEST IS DENIED?
➢ When Arizona Complete Health-Complete Care Plan denies a request for authorization,
a Notice of Adverse Benefit Determination or Notice of Decision (NOD) is mailed to the
member, and an explanation letter is mailed to the requesting provider/ The member’s
Notice of Adverse Benefit Determination will advise the member on how to file an
appeal.
➢ If Arizona Complete Health-Complete Care Plan is reducing, suspending or terminating
an existing service, there are additional rights and rules that apply, other than just being
able to file an appeal.
HOW TO FILL A PRESCRIPTION
All prescriptions should be filled at an in-network pharmacy. You can use our Provider
Directory to find a pharmacy near you. You can access the Provider Director at
www.azcompletehealth.com/completecareon the Find a Provider page. You can also call a
Member Services Representative to help you find a pharmacy. At the pharmacy, you will need
to provide the pharmacist with your prescription and your member ID card.
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If you take medicine for an ongoing health condition, you can have your medicines mailed to
your home. Arizona Complete Health-Complete Care Plan works with a company to give you
this service, which you can get at no cost to you.
If you choose this option, your medicine comes right to your door. You can schedule your refills
and reach pharmacists if you have questions.
Some specialty drugs are only covered when supplied by our specialty pharmacy provider.
Most of these drugs do require a prior authorization.
If you have other insurance besides Medicare Part D, we will only pay the co-pays (if applicable)
if the drug is also on our list of covered drugs.
For pharmacy issues or help after hour, on weekends, or holidays (including if you are turned
away from the pharmacy when you try to get your prescription), please contact Member
Services at 888-788-4408 (TTY/TDY: 711) 24 hours a day, seven days a week.
WHAT YOU NEED TO KNOW ABOUT YOUR NEW PRESCRIPTION
Your doctor or dentist may give you a prescription for medication. Be sure and let your doctor
know about any medications you get from other doctors or medications you buy on your own
including non-prescription or herbal products.
When you pick up your prescription, the pharmacist will talk to you about your new
prescription. Ask your pharmacist about how to take your medication and about any side
effects that could happen. The pharmacy will also give you printed drug information when you
fill your prescription. It will explain what you should and should not do and possible side
effects.
REFILLS
The label on your medication bottle tells you how many refills your doctor has ordered for you.
If your doctor has ordered refills, you may only get up to one 30-day fill at a time. Call your
pharmacy for a refill; they will tell you when you can pick it up.
If your doctor has not ordered refills, you or the pharmacy must call your doctor before your
medication runs out. Talk to your doctor or pharmacy about getting a refill. The doctor may
want to see you before giving you a refill.
WHAT SHOULD I DO IF THE PHARMACY CANNOT FILL MY PRESCRIPTION?
Call Member Services and we can help find out why your prescription cannot be filled.
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Sometimes a primary insurance may be entered wrong or it may be too soon to refill. Other
times the medication is not on our Drug List – our list of covered drugs. If the pharmacy turns
you away or will not fill your prescription, ask if you and the pharmacist can call Member
Services together to find what is happening. We will work with you and the pharmacy to find
the best options for you.
EXCLUSIVE PHARMACIES
Arizona Complete Health-Complete Care Plan wants to keep members safe. Arizona Complete
Health-Complete Care Plan may assign members to a Pharmacy Home or exclusive pharmacy.
Exclusive pharmacies are chosen by the member or assigned by Arizona Complete Health-
Complete Care Plan to provide all medically necessary medications. Members may be assigned
exclusive pharmacies if:
You have utilized the following in a 3 month time period:
More than 4 prescribers;
and
More than 4 different abuse potential drugs;
and
More than 4 Pharmacies.
OR
You have received 12 or more certain medications in the past three months.
OR
You have presented a forged or altered prescription to the pharmacy.
How to !ccess �ehavioral Health Services from !rizona �omplete Health-�omplete �are Plan
Your Primary Care Physician (PCP) may be able to help you if you have mild depression,
“postpartum” depression, anxiety and attention deficit hyperactivity disorder (!DHD)/ Your P�P
may give you medicine, watch how the medicine is working and order different tests for your
illness. You do not need a referral from your PCP for behavioral health services.
As an AHCCCS member, you are also entitled to a wide range of mental health/behavioral
health benefits, including medications. Drugs ordered by your provider are part of your benefit.
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RECEIVING BEHAVIORAL HEALTH SERVICES IF YOU ARE ENROLLED WITH CMDP, DDD, OR ARE DESIGNATED AS SERIOUSLY MENTALLY ILL
If you are enrolled with CMDP, DDD, or are designated as Seriously Mentally Ill, you will
receive your mental health/behavioral health benefits, including medications, from Arizona
Complete Health Regional Behavioral Health Authority (RBHA).
Your AHCCCS ID card has our Member Services phone number to call to access behavioral
health and substance use services. Services are assigned to a provider based on where you live.
If you have questions or need help getting behavioral health services, please call Arizona
Complete Health-�omplete �are Plan’s Member Services/
ELIGIBILITY FOR BEHAVIORAL HEALTH SERVICES
The following members are eligible for behavioral health services:
➢ Persons AHCCCS eligible through either Title 19 (Medicaid) or Title 21;
➢ Persons determined to have a Serious Mental Illness; and
➢ Special populations who are eligible to receive services funded through federal block
grants.
Title 19 (Medicaid; may also be called AHCCCS) is insurance for low-income persons, children,
and families. It pays for medical, dental (for children up to 21 years of age), and behavioral
health services.
Title 21 (May also be called AHCCCS) is insurance for children under the age of 19 who do not
have insurance and are not eligible for Title 19 benefits. It pays for medical, dental, and
behavioral health services.
A Serious Mental Illness (SMI) is a mental disorder in persons 18 years of age or older that is
severe and persistent. Persons may be so impaired that they cannot remain in the community
without treatment and/or services. Crisis Response Network, a contracted provider with
Arizona Complete Health-Complete Care Plan, will make a determination of Serious Mental
Illness upon referral/request.
HOW TO ACCESS BEHAVIORAL HEALTH SERVICES
Arizona Complete Health-Complete Care Plan contracts with a variety of providers to meet
your behavioral health needs. Contracted providers are chosen very carefully. They must
meet strict requirements to care for our members, and we regularly check the care they give
you. Arizona Complete Health-Complete Care Plan’s provider network covers a broad
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geographic area so that you may receive services close to where you live and work. Our
provider network offers culturally sensitive, individualized and comprehensive service
options for children and families, and those with general mental health and substance abuse
issues. You can select a provider from our provider directory or call Member Services for
assitance.
!RIZON!’S VISION FOR THE DELIVERY OF BEHAVIORAL HEALTH SERVICES
All behavioral health services are delivered according to the following system principles. AHCCCS supports a behavioral health delivery system that includes:
1. Easy access to care, 2. Behavioral health recipient and family member involvement, 3. Collaboration with the Greater Community, 4. Effective Innovation, 5. Expectation for Improvement, and 6. Cultural Competency.
THE TWELVE PRINCIPLES FOR THE DELIVERY OF SERVICES TO CHILDREN:
1. Collaboration with the child and family: a. Respect for and active collaboration with the child and parents is the cornerstone to
achieving positive behavioral health outcomes, and b. Parents and children are treated as partners in the assessment process, and the
planning, delivery, and evaluation of behavioral health services, and their preferences are taken seriously.
2. Functional outcomes: a. Behavioral health services are designed and implemented to aid children to achieve
success in school, live with their families, avoid delinquency, and become stable and productive adults, and
b. Implementation of the behavioral health services plan stabilizes the child’s condition and minimizes safety risks.
3. Collaboration with others: a. When children have multi-agency, multi-system involvement, a joint assessment is
developed and a jointly established behavioral health services plan is collaboratively implemented,
b. Client-centered teams plan and deliver services, and c. Each child’s team includes the child and parents and any foster parents, any individual important in the child’s life who is invited to participate by the child or parents. The team also includes all other persons needed to develop an effective
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plan, including, as appropriate, the child’s teacher, the child’s D�S and/or DDD caseworker, and the child’s probation officer/
d. The team: i. Develops a common assessment of the child’s and family’s strengths and needs, ii. Develops an individualized service plan, iii. Monitors implementation of the plan, and iv. Makes adjustments in the plan if it is not succeeding.
4. Accessible services: a. Children have access to a comprehensive array of behavioral health services,
sufficient to ensure that they receive the treatment they need, b. Case management is provided as needed, c. Behavioral health service plans identify transportation the parents and child need to
access behavioral health services, and how transportation assistance will be provided, and
d. Behavioral health services are adapted or created when they are needed but not available.
5. Best practices: a. Behavioral health services are provided by competent individuals who are trained
and supervised, b. Behavioral health services are delivered in accordance with guidelines that
incorporate evidence-based “best practices/” c. Behavioral health service plans identify and appropriately address behavioral
symptoms that are reactions to death of a family member, abuse or neglect, learning disorders, and other similar traumatic or frightening circumstances, substance abuse problems, the specialized behavioral health needs of children who are developmentally disabled, maladaptive sexual behavior, including abusive conduct and risky behavior, and the need for stability and the need to promote permanency in class members’ lives, especially class members in foster care, and
d. Behavioral health services are continuously evaluated and modified if ineffective in achieving desired outcomes.
6. Most appropriate setting: a. Children are provided behavioral health services in their home and community to
the extent possible, and b. Behavioral health services are provided in the most integrated setting appropriate to the child’s needs/ When provided in a residential setting, the setting is the most integrated and most home-like setting that is appropriate to the child’s needs/
7. Timeliness: a. Children identified as needing behavioral health services are assessed and served
promptly.
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8. Services tailored to the child and family: a. The unique strengths and needs of children and their families dictate the type, mix,
and intensity of behavioral health services provided, and b. Parents and children are encouraged and assisted to articulate their own strengths
and needs, the goals they are seeking, and what services they think are required to meet these goals.
9. Stability: a. Behavioral health service plans strive to minimize multiple placements, b. Service plans identify whether a class member is at risk of experiencing a placement
disruption and, if so, identify the steps to be taken to minimize or eliminate the risk, c. Behavioral health service plans anticipate crises that might develop and include
specific strategies and services that will be employed if a crisis develops, d. In responding to crises, the behavioral health system uses all appropriate behavioral
health services to help the child remain at home, minimize placement disruptions, and avoid the inappropriate use of the police and the criminal justice system, and
e. Behavioral health service plans anticipate and appropriately plan for transitions in children’s lives, including transitions to new schools and new placements, and transitions to adult services.
10. Respect for the child and family’s unique cultural heritage. a. Behavioral health services are provided in a manner that respects the cultural
tradition and heritage of the child and family, and b. Services are provided in Spanish to children and parents whose primary language is
Spanish.
11. Independence: a. Behavioral health services include support and training for parents in meeting their child’s behavioral health needs, and support and training for children in self-management, and
b. �ehavioral health service plans identify parents’ and children’s need for training and support to participate as partners in the assessment process, and in the planning, delivery, and evaluation of services, and provide that such training and support, including transportation assistance, advance discussions, and help with understanding written materials, will be made available.
12. Connection to natural supports: a. The behavioral health system identifies and appropriately utilizes natural supports available from the child and parents’ own network of associates, including friends and neighbors, and from community organizations, including service and religious organizations.
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NINE GUIDING PRINCIPLES FOR RECOVERY-ORIENTED ADULT BEHAVIORAL HEALTH SERVICES AND SYSTEMS
1. Respect - Respect is the cornerstone. Meet the person where they are without judgment, with great patience and compassion.
2. Persons in recovery choose services and are included in program decisions and program development efforts - A person in recovery has choice and a voice. Their self-determination in driving services, program decisions and program development is made possible, in part, by the ongoing dynamics of education, discussion, and evaluation, thus creating the “informed consumer” and the broadest possible palette from which choice is made. Persons in recovery should be involved at every level of the system, from administration to service delivery.
3. Focus on individual as a whole person, while including and/or developing natural supports - A person in recovery is held as nothing less than a whole being: capable, competent, and respected for their opinions and choices. As such, focus is given to empowering the greatest possible autonomy and the most natural and well-rounded lifestyle. This includes access to and involvement in the natural supports and social systems customary to an individual’s social community/
4. Empower individuals taking steps towards independence and allowing risk taking without fear of failure - A person in recovery finds independence through exploration, experimentation, evaluation, contemplation and action. An atmosphere is maintained whereby steps toward independence are encouraged and reinforced in a setting where both security and risk are valued as ingredients promoting growth.
5. Integration, collaboration, and participation with the community of one’s choice - A person in recovery is a valued, contributing member of society and, as such, is deserving of and beneficial to the community/ Such integration and participation underscores one’s role as a vital part of the community, the community dynamic being inextricable from the human experience. Community service and volunteerism is valued.
6. Partnership between individuals, staff and family members/natural supports for shared decision making with a foundation of trust - A person in recovery, as with any member of a society, finds strength and support through partnerships. Compassion-based alliances with a focus on recovery optimization bolster self-confidence, expand understanding in all participants and lead to the creation of optimum protocols and outcomes.
7. Persons in recovery define their own success - ! person in recovery − by their own declaration − discovers success, in part, by quality of life outcomes, which may include an improved sense of well being, advanced integration into the community, and greater self-determination. Persons in recovery are the experts on themselves, defining their own goals and desired outcomes.
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8. Strengths-based, flexible, responsive services reflective of an individual’s cultural preferences - A person in recovery can expect and deserves flexible, timely and responsive services that are accessible, available, reliable, accountable and sensitive to cultural values and mores. A person in recovery is the source of his/her own strength and resiliency. Those who serve as supports and facilitators identify, explore and serve to optimize demonstrated strengths in the individual as tools for generating greater autonomy and effectiveness in life.
9. Hope is the foundation for the journey towards recovery - A person in recovery has the capacity for hope and thrives best in associations that foster hope. Through hope, a future of possibility enriches the life experience and creates the environment for uncommon and unexpected positive outcomes to be made real. A person in recovery is held as boundless in potential and possibility.
Multispecialty Interdisciplinary �linics
CHILDREN’S REH!�ILIT!TIVE SERVICES (CRS) PROVIDER: MULTISPECIALTY INTERDISCIPLINARY CLINICS
If your child is diagnosed with certain conditions, they are eligible for services from special
providers through a program called �hildren’s Rehabilitative Services (�RS)/ These providers are
called Multispecialty Interdisciplinary Clinics. Members with qualifying CRS conditions may
choose to obtain services from any in-network Health Plan contracted provider; including,
Multispecialty Interdisciplinary Clinics (MSICs) which serve as Health Homes that provide multi-
specialty services to members with complex needs. At the MSIC, you and your family can see
all of your medical specialists, benefit from community involvement and conveniently receive
support services in one location.
Arizona Complete Health-Complete Care Plan can provide additional information and answer
questions about MSICs, please call 1-888-788-4408, TTY/TDY 711 to speak to a Member
Services representative.
If AHCCCS determines that your child is eligible for the CRS program, your child will be enrolled in a plan with a CRS provider.
Once your child is a CRS Member, your child will receive an Identification (ID) card from Arizona Complete Health-Complete Care Plan/ The ID card has your child’s name, �RS ID number, and other important information.
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The type of �RS medical provider who will treat your child’s condition will depend on your
child’s special health care need/ Your child’s �RS medical provider may be one of the following.
➢ Surgeon: General pediatric surgeon, Cardiovascular and thoracic surgeon, Ear, Nose and Throat (ENT) surgeon, Neurosurgeon, Ophthalmology surgeon, Orthopedic surgeons (general, hand, scoliosis, amputee), Plastic surgeons
➢ Medical Specialist: Cardiologist, Neurologist, Rheumatologist, General Pediatrician, Geneticist, Urologist, Metabolic Specialist
➢ Dental Provider: Dentist, Orthodontist
For more details on the clinic's specialties, you can visit the clinic's website or contact the clinic
directly; or you may call Arizona Complete Health-Complete Care Plan Member Services at 1-
888-788-4408 (TTY/TDY: 711). CRS Multispecialty Interdisciplinary Clinics are at the following
locations:
DMG �hildren’s Rehabilitative Services 3141 N. 3rd Ave Phoenix, AZ 85013 1-602-914-1520 1-855-598-1871 www.dmgcrs.org DMG �hildren’s Rehabilitative Services specializes in the following services. !udiology,
Cardiology, Endocrinology, ENT, Gastroenterology, Genetics, Lab and X-Ray, Neurology,
Neurosurgery, Nutrition, Occupational Therapy, Ophthalmology, Orthopedics, Pediatric
Surgery, Physical Therapy, Plastic Surgery, Primary Care, Psychology, Rheumatology, Scoliosis,
Speech and Language Rehabilitation, and Urology.
�hildren’s �linics Square & Compass Building 2600 North Wyatt Drive Tucson, AZ 85712 1-520-324-5437 1-800-231-8261 www.childrensclinics.org �hildren’s �linics specializes in the following services. !nesthesiology, !udiology, �ardiology,
Child Life, Dental and Orthodontia, Educational Support, Endocrinology, ENT, Gastrointestinal,
Genetics, Lab and X-Ray, Hematology, Nephrology, Neurosurgery, Nursing Services, Nutrition,
Occupational Therapy, Orthopedics, Ophthalmology, “Our �est Friends” Pet Therapy Program,
Patient and Family Services, Pediatric Surgery, Physical Medicine, Physical Therapy, Plastic
Surgery, Primary Care, Psychology, Pulmonology, Rheumatology, Speech and Language
Therapy, and Urology.
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�hildren’s Rehabilitative Services 1200 North Beaver Flagstaff, AZ 86001 1-928-773-2054 1-800-232-1018 www.flagstaffmedicalcenter.com
Flagstaff Medical Center specializes in the following services: Audiology, Bariatric Surgical
Weight Loss, �ehavioral Health, �ancer �enters, �hildren’s Health �enter, Diabetes, Emergency
Care, Endocrinology, Gastroenterology, Surgical Services, Fit Kids, Heart and Vascular, Infectious
Diseases. Neurology, Nutrition Services, Ophthalmology, Orthopedics, Pulmonary, Renal
Services, Sleep Center, Trauma Services, EntireCare Therapy, and Urology.
�hildren’s Rehabilitative Services 2400 Avenue A Yuma, AZ 85364 1-928-336-7095 1-800-837-7309 www.yumaregional.org
Yuma Regional Medical Center specializes in the following services: Cardiology,
Gastroenterology, Neonatal ICU, Nephrology, Neurology, Rheumatology, Surgery, and Urology.
HOW TO MAKE, CHANGE OR CANCEL AN APPOINTMENT WITH A CRS CLINIC
Your child needs to have an appointment to see a �RS provider/ If you don’t make an appointment and just show up, the provider may not be able to see your child. When you call the Multispecialty Interdisciplinary Clinics (MSIC) to make an appointment, be ready to tell the person on the phone:
• Your child’s name • Your child’s AHCCCS ID number, and
• The reason your child needs an appointment.
Your child’s appointment will be made based on when your provider needs to see your child or within 45 days. If your child has an urgent need, your child can see your provider sooner. If you think your child’s appointment needs to be made sooner, you can ask to be seen at an earlier date. Please tell the provider why you think your child needs to be seen quickly and ask for an earlier appointment.
If you need to cancel or change an appointment, please tell your child’s provider or your clinic at least one day before the appointment. If you need to cancel an appointment, please be sure to make an appointment for another time.
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If you need assistance with making, canceling, or rescheduling an appointment, Arizona Complete Health-Complete Care Plan can help. Please call Member Services at 1-888-788-4408 (TTY/TDY: 711).
�hildren’s Rehabilitative Services (�RS) What is CRS? �hildren’s Rehabilitative Services (�RS) is a designation given to certain !H���S members who have qualifying health conditions. Members with a CRS designation can get the same AHCCCS covered services as non-CRS AHCCCS members and are able to get care in the community, or in clinics called multispecialty interdisciplinary clinics (MSIC). MSICs bring many specialty providers together in one location. Your health plan will assist a member with a CRS designation with closer care coordination and monitoring to make sure special healthcare needs are met.
Eligibility for a CRS designation is determined by the AHCCCS Division of Member Services (DMS). Who is Eligible for a CRS Designation? AHCCCS members may be eligible for a CRS designation when they are: ➢ Under age 21; and ➢ Have a qualifying CRS medical condition
The medical condition must: ➢ Require active treatment; and ➢ Be found by AHCCCS DMS to meet criteria as specified in R9-22-1301-1305.
Anyone can fill out a CRS application including a family member, doctor, or health plan representative. To apply for a CRS designation mail or fax: ➢ A completed CRS application; and ➢ Medical documentation that supports that the applicant has a CRS qualifying condition
that requires active treatment.
Arizona Complete Health will provide medically necessary care for physical and behavioral health services and care for the CRS condition.
CONDITIONS COVERED THROUGH THE CRS PROGRAM
CRS covers many chronic and disabling health conditions. Some of the eligible conditions
include, but are not limited to:
➢ Cerebral palsy
➢ Club feet
➢ Dislocated hips
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➢ Cleft palate
➢ Scoliosis
➢ Spina bifida
➢ Heart conditions due to congenital anomalies
➢ Metabolic disorders
➢ Neurofibromatosis
➢ Sickle cell anemia
➢ Cystic Fibrosis
EARLY CHILDHOOD SERVICES*
If you are concerned that your child is not growing like other children of the same age, tell your
pediatrician or family doctor. Your doctor can refer you to specialists to learn if your child is on
track with talking, moving, using hands and fingers, seeing and hearing. If your child is behind in
one or more of these areas, services are available to help you help your child improve in these
areas. The doctor may refer you to the Arizona Early Intervention Program (AzEIP) if your child
is birth to three years of age and has a delay. To learn more about other community programs
for children with special needs call Member Services at 1-888-788-4408 (TTY/TDY: 711).
*A well-child visit/check is the same as an EPSDT.
HEAD START
Arizona Head Start Programs provide high quality programs for preschool age children that
include early childhood education, nutrition, health, mental health, disabilities and social
services. In some areas there are early Head Start programs for infants and toddlers three years
of age. There are Head Start Services at over 500 locations throughout the State of Arizona. For
more information about the Head Start nearest you, call 1-866-763-6481. You will need your
address and zip code when you call.
DEVELOPMENTAL SCREENING TOOLS
Developmental screening tools used by PCPs providing care for children include:
➢ For members who are 9, 18 and 24 months of age, the Parent’s Evaluation ofDevelopmental Status (PEDS) tool and the Ages and Stages Questionnaire (ASQ).
➢ For members 16-30 months of age, the Modified Checklist for Autism in Toddlers (MCHAT), to screen for autism when medically indicated.
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Special !ssistanceSpecial Assistance is a unique clinical designation providing support to members with an SMI
determination. Qualifying members must have an inability to communicate and/or participate
during treatment planning and have a qualifying mental and/or physical condition. When a
health home clinical team or other qualified assessor determines a member meets Special
Assistance criteria they notify the Office of Human Rights. The Office of Human Rights will
assign an individual to meet Special Assistance needs who advocates on behalf of the member
during treatment planning.
Arizona Complete Health-Complete Care Plan works in collaboration with the AHCCCS Office of
Human Rights to ensure members meeting Special Assistance criteria are appropriately
identified.
You can reach the Individual & Family Affairs team by calling Member Services at 1-888-788-
4408 (TTY/TDY: 711) and asking to speak to someone from the Individual & Family Affairs Team.
You can visit the AHCCCS Office of Human Rights page at:
https://www.azahcccs.gov/AHCCCS/HealthcareAdvocacy/ or call: 1-877-524-6882
Member !dvocacy �ouncil You’ll find Arizona Complete Health-Complete Care Plans’s !dvocate Team at work in
community coalitions, committees, and workgroups promoting and protecting your rights as an
AHCCCS member. Our advocacy team also holds monthly Member Advocacy Council meetings.
This is an opportunity to have your voice heard and to learn about changes or updates in your
health plan.
Arizona Complete Health-Complete Care Plans’s !dvocate Team is made up of the following
staff:
Member Advocacy
Administrator
Oversees Arizona Complete Health-Complete Care Plans’s !dvocacy
team and works with members with special healthcare needs,
families, youth, advocates and key stakeholders to promote and
protect their rights. Works closely with regional Human Rights
Committees and the Office of Human Rights.
Adult Behavioral Health
Member Advocate
Focused on promoting and protecting the rights of adult members
receiving behavioral health services. This includes Special
Assistance and the Office of Human Rights.
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Child Behavioral Health
Member Advocate
Focused on promoting and protecting the rights of children
receiving behavioral health services.
Veteran Member Advocate Focused on promoting and protecting the rights of our veteran
members receiving physical and/or behavioral health services.
CRS Member Advocate
Focused on promoting and protecting the rights of our members
receiving physical and/or behavioral health services through the
CRS program. Children’s Rehabilitative Services (�RS) is an !rizona
program that provides medical treatment to AHCCCS members with
CRS-qualifying conditions. CRS members receive the same AHCCCS
covered services as non-CRS AHCCCS members. Services are
provided for the CRS condition and other medical and behavioral
health services for most CRS members. CRS members are able to
receive care in the community, or in multispecialty interdisciplinary
clinics (MSICs).
Please contact us at [email protected] for more information on advocacy
or to be a part of our Member Advocacy Council. You may also contact Member Services by
calling 1-888-788-4408 (TTY/TDY: 711) and ask to speak to a Member Advocacy Council
representative.
!pproval and Denial Process Some medical and behavioral health services may need Prior Authorization. Prior Authorization
means your doctor has requested permission for you to get a special service or referral. We
must approve these requests before the delivery of services. For example, non-emergency
hospital admissions or others such as:
➢ Behavioral Health Inpatient Facility ➢ Behavioral Health Residential Facility ➢ Home Care Training to Home Care Clients (HCTC) ➢ Psychological and Neuropsychological Testing ➢ Electroconvulsive Therapy (ECT) ➢ Non-emergency out of network services/treatments ➢ Some medications, check the list of approved medications (formulary) ➢ MRI, MRA, PET scans ➢ Special lab work, genetics
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➢ Surgeries, pre-scheduled ➢ Dialysis ➢ Some Outpatient procedures and surgeries ➢ Transplant ➢ Bio pharmacy (Buy and Bill)
If they do, your provider will arrange for authorization for these services. We must review these
authorization requests before you can get the service.
If you or your provider would like a referral to a service that is not a covered benefit, please
call Member Services at 1-888-788-4408, TTY/TDY 711 so we can discuss other options
available to you.
Prior Authorization is approved based on a review of medical need.
Your provider will let you know when authorization is obtained. You can also call Member
Services to find out the status of the request. We will let you know by mail if authorization is
denied. In the letter, you will have instructions on how to file an appeal. The letter will describe
the reason for the denial. If you have a question about the denial and need help, please call
Member Services at 1-888-788-4408, TTY/TDY 711. Please see the section titled “Complaints:
What Should I Do if I !m Unhappy?” in this handbook for more information about filing an
appeal about a denied authorization.
Criteria that decisions are based on are available upon request.
In-Network Referrals and Freedom of �hoice of Providers
You are required to use a Health Plan in-network specialty provider. You can find Health Plan
contracted in-network specialty providers on our website;
azcompletehealth.com/completecare
The Health Plan offers members the freedom of choice in selecting doctors and specialists in
our network. Arizona Complete Health-Complete Care Plan members are not restricted in their
choice of network providers. In cases where an in-network provider is not available, Arizona
Complete Health-Complete Care Plan may authorize non-emergency out of network services or
treatments.
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�opayments
COPAYMENTS
Some people who get AHCCCS Medicaid benefits are asked to pay copayments for some of the AHCCCS medical services that they receive.
*Note: Copayments referenced in this section means copayments charged under Medicaid (AHCCCS). It does not mean a person is exempt from Medicare copayments.
THE FOLLOWING PERSONS ARE NOT ASKED TO PAY COPAYMENTS: ➢ People under age 19, ➢ People determined to be Seriously Mentally Ill (SMI), ➢ !n individual designated eligible for �hildren’s Rehabilitative Services (�RS) pursuant
to as Title 9, Chapter 22, Article 13. , ➢ ACC, CMDP, and RBHA members who are residing in nursing facilities or residential facilities such as an !ssisted Living Home and only when member’s medical condition would otherwise require hospitalization. The exemption from copayments for these members is limited to 90 days in a contract year,
➢ People who are enrolled in the Arizona Long Term Care System (ALTCS), ➢ People who are Qualified Medicare Beneficiaries, ➢ People who receive hospice care, ➢ American Indian members who are active or previous users of the Indian Health
Service, tribal health programs operated under Public Law 93-638, or urban Indian health programs,
➢ People in the Breast and Cervical Cancer Treatment Program (BCCTP), ➢ People receiving child welfare services under Title IV-B on the basis of being a child in
foster care or receiving adoption or foster care assistance under Title IV-E regardless of age,
➢ People who are pregnant and throughout postpartum period following the pregnancy, and
➢ Individuals in the adult Group (for a limited time**).
**Note: For a limited time persons who are eligible in the Adult Group will not have any copays. Members in the Adult Group include persons who were transitioned from the AHCCCS Care program as well as individuals who are between the ages of 19-64, and who are not entitled to Medicare, and who are not pregnant, and who have income at or below 133% of the Federal Poverty Level (FPL) and who are not AHCCCS eligible under any other category. Copays for persons in the Adult Group with income over 106% FPL are planned for the future. Members will be told about any changes in copays before they happen.
IN ADDITION, COPAYMENTS ARE NOT CHARGED FOR THE FOLLOWING SERVICES FOR ANYONE: ➢ Hospitalizations,
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➢ Emergency services, ➢ Family Planning services and supplies, ➢ Pregnancy related health care and health care for any other medical condition that
may complicate the pregnancy, including tobacco cessation treatment for pregnant women,
➢ Preventive services, such as well visits, pap smears, colonoscopies, mammograms and immunizations,
➢ Provider preventable services, and ➢ Services received in the emergency department.
PEOPLE WITH OPTIONAL (NON-MANDATORY) COPAYMENTS Individuals eligible for AHCCCS through any of the programs below may be charged non-mandatory copays, unless:
1. They are receiving one of the services above that cannot be charged a copay, or 2. They are in one of the groups above that cannot be charged a copay.
Non-mandatory copays are also called optional copays. If a member has a non-mandatory copay, then a provider cannot deny the service if the member states that s/he is unable to pay the copay. Members in the following programs may be charged non-mandatory copay by their provider:
➢ AHCCCS for Families with Children (1931), ➢ Young Adult Transitional Insurance (YATI) for young people in foster care, ➢ State Adoption Assistance for Special Needs Children who are being adopted, ➢ Receiving Supplemental Security Income (SSI) through the Social Security
Administration for people who are age 65 or older, blind or disabled, ➢ SSI Medical Assistance Only (SSI MAO) for individual who are age 65 or older, blind or
disabled, ➢ Freedom to Work (FTW).
Ask your provider to look up your eligibility to find out what copays you may have. You can also find out by calling Arizona Complete Health-Complete Care Plan member services. You can also check the Arizona Complete Health-Complete Care Plan website for more information.
AHCCCS members with non-mandatory copays may be asked to pay the following non-mandatory copayments for medical services:
OPTIONAL (NON-MANDATORY) COPAYMENT AMOUNTS FOR SOME MEDICAL SERVICES
Service Copayment
Prescriptions $2.30
Out-patient services for physical, occupational and speech therapy $2.30
Doctor or other provider outpatient office visits for evaluation and management of your care
$3.40
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Medical providers will ask you to pay these amounts but will NOT refuse you services if you are unable to pay. If you cannot afford your copay, tell your medical provider you are unable to pay these amounts so you will not be refused services.
PEOPLE WITH REQUIRED (MANDATORY) COPAYMENTS Some AHCCCS members have required (or mandatory) copays unless they are receiving one of the services above that cannot be charged a copay or unless they are in one of the groups above that cannot be charged a copay. Members with required copays will need to pay the copays in order to get the services. Providers can refuse services to these members if they do not pay the mandatory copays. Mandatory copays are charged to persons in Families with Children that are no Longer Eligible Due to Earnings - also known as Transitional Medical Assistance (TMA)
Adults on TMA have to pay required (or mandatory) copays for some medical services. If you are on the TMA Program now or if you become eligible to receive TMA benefits later, the notice from DES or AHCCCS will tell you so. Copays for TMA members are listed below.
REQUIRED (MANDATORY) COPAYMENT AMOUNTS FOR PERSONS RECEIVING TMA BENEFITS
Service Copayment
Prescriptions $2.30
Doctor or other provider outpatient office visits for evaluation and management of your care
$4.00
Physical, Occupational and Speech Therapies $3.00
Outpatient Non-emergency or voluntary surgical procedures $3.00
Pharmacists and Medical Providers can refuse services if the copayments are not made.
5% LIMIT ON ALL COPAYMENTS The amount of total copays cannot be more than 5% of the family’s total income (before taxes and deductions) during a calendar quarter (January through March, April through June, July through September, and October through December.) The 5% limit applies to both nominal and required copays.
!H���S !dministration will track each member’s specific copayment levels to identify members who have reached the 5% copayment limit. If you think that the total copays you have paid are more than 5% of your family’s total quarterly income and !H���S has not already told you this has happened, you should send copies of receipts or other proof of how much you have paid to AHCCCS, 801 E. Jefferson, Mail Drop 4600, Phoenix, Arizona 85034.
If you are on this program but your circumstances have changed, contact your local DES office to ask them to review your eligibility. Members can always request a reassessment of their 5% limit if their circumstances have changed.
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Paying for �overed ServicesOnly in very limited circumstances should you be asked to pay for covered services. Doctors,
hospitals, and pharmacies can verify your coverage through AHCCCS or by calling Arizona
Complete Health-Complete Care Plan Member Service. If you have been asked to pay for a
covered service or if you have received a bill for covered services, please contact Member
Services to discuss your options for reimbursement.
Paying for non-covered services We will only cover care approved by our plan, unless it is an Emergency Service. If you obtain a
service or prescription that is not covered by our plan, Arizona Complete Health-Complete Care
Plan will not be responsible for payment.
�oordination Of �enefits (�O�)
AHCCCS is the payer of last resort. This means AHCCCS shall be used as a source of payment for
covered services only after all other sources of payment have been exhausted.
If you are a member with “other insurance” or are “dual eligible” (which means that you also
have Medicare coverage), please take a moment to call Member Services to let us know. When
you call us, we will make sure we have the other insurance listed in our system.
You may also call the AHCCCS eligibility office to let them know. AHCCCS will then pass the
information on to us. Remember, this also includes insurance coverage through divorce or if
your child has insurance that is paid by your former spouse. Sometimes, members with other
types of insurance such as Tricare or other commercial plans are approved for AHCCCS. We are
responsible for making any co-payment, coinsurance or deductibles, even if the services are
provided outside of our network.
If a third party insurer (other than Medicare) requires the member to pay any co-payment,
coinsurance or deductible, we are responsible for paying the lesser of the difference between:
➢ The Primary Insurance Paid amount and the Primary Insurance Rate (i/e/, the member’s
co-payment required under the Primary Insurance).
OR
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➢ The Primary Insurance Paid amount and the AHCCCS Fee for Service Rate, even if the
services are provided outside of the network.
We are not responsible for paying coinsurance and deductibles that are more than what we
would have paid for the entire service per the contract with the provider performing the
service, or the AHCCCS equivalent
Arizona Complete Health-Complete Care Plan takes reasonable measures to find out who may
be legally required to pay all or part of covered services. This is called establishing liability.
The two methods used for coordination of benefits are Cost Avoidance and Post-Payment
Recovery.
Cost avoidance means that we cost avoid a claim if we may have established that there is a
liable party, such as other insurance that should be covering the cost.
Post-Payment Recovery means that if we find out that there was a liable party after we have
paid a claim, we will recover the cost of that claim.
AHCCCS is the payor of last resort unless specifically prohibited by applicable state or federal
law. This means AHCCCS shall be used as a source of payment for covered services only after all
other sources of payment have been exhausted. Arizona Complete Health-Complete Care Plan
will take reasonable measures to identify potentially legally liable third-party sources
Special Information for our Members who have Medicare �overage
If you are a “dual eligible” member, it often means that you have additional benefits that may
not be covered under AHCCCS. When we know about your other insurance, it helps us
coordinate the care you receive with the other plan.
If you have Medicare coverage and you see a doctor that is out of our network, the charges
may not be covered. Arizona Complete Health-Complete Care Plan may not pay for services if
you decide to see a doctor outside of our network without our prior authorization. If you would
like to see a doctor outside of our network, please call our member services to discuss your
options. It is important that you work with your PCP to be referred to the right doctors. We will
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not cover copays or deductibles for services provided outside of the network without Prior
Authorization.
Prior Authorization is not required for emergency services.
Dual eligible members have a choice of all providers in the network and are not restricted to
those that accept Medicare.
Why should you call Member Services and let us know about the different coverage that you
have? Because it will help you get the maximum benefits from both insurance plans!
IMPORTANT INFORMATION FOR AHCCCS MEMBERS WITH MEDICARE PART D COVERAGE
(DUAL ELIGIBLE MEMBERS)
AHCCCS does not pay for any drugs paid by Medicare Part D, or for the cost sharing of these
drugs. Cost sharing refers to coinsurance, deductibles, and/or copayments.
AHCCCS does not pay for barbiturates to treat epilepsy, cancer, or mental health problems or
any benzodiazepines for members with Medicare. AHCCCS pays for barbiturates for Medicare
members that are not used to treat epilepsy, cancer, or chronic mental health conditions.
�omplaints. How to File and �omplaint If I !m Unhappy GRIEVANCES AND APPEALS
If you are dissatisfied with your services or disagree with a decision made about your services,
make your voice heard by contacting the Arizona Complete Health-Complete Care Plan
Grievance and Appeals Department. You always have the right to file a grievance and we are
here to support you. The Arizona Complete Health-Complete Care Plan Grievance and Appeals
Department will help you with the process for filing a grievance or an appeal.
DISSATISFIED WITH YOUR CARE?
If you are not happy with your care you may file a grievance. A grievance is a complaint. You may
file a grievance against a service provider or against Arizona Complete Health-Complete Care
Plan. Examples of grievances include delays in services and dissatisfaction with the quality of care
or quality of service you received.
You may also file a grievance if you received a Notice of Adverse Benefit Determination that you
do not understand or is not correct. If Arizona Complete Health-Complete Care Plan does not
75
resolve your concern about the Notice, you may also contact AHCCCS Medical Management at
You may also file a grievance by calling the Member Services Department between 8:00 a.m. and
5:00 p.m. at 1-888-788-4408 or TTY/TDY 711.
You may also file a grievance in person or in writing. You may file your grievance in writing by
mailing it to:
Arizona Complete Health – Complete Care Plan Attn: Grievance and Appeals Department 1870 W. Rio Salado Parkway Tempe, AZ 85281
Once filed, your grievance will be reviewed and a response will be provided no later than 90 days
from the date that you contacted us. In most cases we will complete our review and provide a
response within 10 calendar days.
DISSATISFIED WITH A DECISION?
If you are not happy with a decision made about your services, you may file an Appeal. An
appeal is a formal request to review a decision about your services. If you receive a Notice of
Adverse Benefit Determination, you have the right to file an appeal. A Notice of Adverse Benefit
Determination is a written letter that explains a decision about your services. Even if you did
not receive a Notice of Adverse Benefit Determination, you may have the right to file an appeal.
You have appeal rights regarding any covered service we provide; this includes appeals for Title
19/21 AHCCCS eligible members and appeals for members who are not enrolled as a person
with Serious Mental Illness and are Non-Title 19/21 eligible.
HOW DO I FILE AN APPEAL?
Appeals can be filed orally or in writing within 60 days after the date of a Notice of Adverse
Benefit Determination or Notice of Decision and Right to Appeal. The Notice explains to you
how to file an appeal and what the deadline is for filing an appeal. However, if you have any
questions the Arizona Complete Health Grievance and Appeal Department is available to assist
you. To reach a Grievance and Appeal Department representative, please contact Arizona
Complete Health-Complete Care Plan Member Services.
You or your legal representative can file an appeal. An authorized representative, including a
provider, can also file an appeal for you with your written permission. You can also get help
with filing an appeal by yourself.
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In some cases, Arizona Complete Health-Complete Care Plan will review an appeal on an
expedited basis. An expedited appeal is resolved within 72 hours due to the urgent health
needs of the person filing the appeal. Contact Arizona Complete Health-Complete Care Plan
Member Services or your provider to see if your appeal will be expedited. If your appeal is not
expedited it will be resolved within 30 calendar days of the date it is received.
To file an appeal orally or for help with filing a written appeal, call Arizona Complete Health-
Complete Care Plan Member Services at 1-888-788-4408 or TTY/TDY 7-1-1. To file an appeal by
mail, send your appeal and documentation to:
Arizona Complete Health
Attn: Grievance & Appeal Department
1870 W. Rio Salado Parkway
Tempe, AZ 85281
You will get written notice that your appeal was received within 5 business days. If your appeal
is expedited, you will get notice that your appeal was received within 1 business day. If Arizona
Complete Health-Complete Care Plan has decided that your appeal does not need to be
expedited, your appeal will follow the standard appeal timelines. Arizona Complete Health-
Complete Care Plan will make reasonable efforts to give you prompt oral notice of the decision
not to expedite your appeal and follow up within 2 calendar days with a written notice.
WHAT CAN I APPEAL?
You have the right to ask for a review of the following adverse benefit determinations:
• The denial or limited approval of a service asked for by your provider or clinical team;
• The reduction, suspension, or termination of a service that you were receiving;
• The denial, in whole or part, of payment for a service;
• The failure to provide services in a timely manner;
• The failure to act within timeframes for resolving an appeal or complaint; and
• The denial of a request for services outside of the provider network when services are
not available within the provider network.
WHAT HAPPENS AFTER I FILE AN APPEAL?
As part of the appeal process, you have the right to give evidence that supports your appeal.
You can provide the evidence to Arizona Complete Health-Complete Care Plan in person or in
writing. In order to prepare for your appeal, you may examine your case file, medical records,
and other documents and records that may be used before and during the appeal process, as
long as the documents are not protected from disclosure by law. If you would like to review
these documents, contact your provider or Arizona Complete Health-Complete Care Plan. The 77
evidence you give to Arizona Complete Health-Complete Care Plan will be used when deciding
the resolution of the appeal.
HOW IS MY APPEAL RESOLVED?
Arizona Complete Health-Complete Care Plan will give you a decision, called a Notice of Appeal
Resolution, in person or by certified mail within 30 days of getting your appeal for standard
appeals, or within 72 hours for expedited appeals. The Notice of Appeal Resolution is a written
letter that tells you the results of your appeal.
The resolution date may be may be extended by up to 14 days. You or Arizona Complete
Health-Complete Care Plan can ask for more time in order to gather more information. If
Arizona Complete Health-Complete Care Plan asks for more time, you will be given written
notice of the reason for the extension.
When we have completed our review, you will receive a Notice of Appeal Resolution that will
tell you:
• The outcome of the appeal; and
• The reason(s) for the decision
If your appeal was denied, in whole or in part, then the Notice of Appeal Resolution will also tell
you:
• How you can ask for a State Fair Hearing;
• How to ask that services continue during the State Fair Hearing process, if applicable;
• The reason why your appeal was denied and the legal basis for the decision to deny your
appeal; and
• That you may have to pay for the services you get during the State Fair Hearing process
if your appeal is denied at the State Fair Hearing.
WHAT CAN I DO IF I AM NOT HAPPY WITH MY APPEAL RESULTS?
You can ask for a State Fair Hearing if you are not happy with the results of an appeal. If your
appeal was expedited, you can ask for an expedited State Fair Hearing. YOU HAVE THE RIGHT
TO HAVE A REPRESENTATIVE OF YOUR CHOICE ASSIST YOU AT THE STATE FAIR HEARING.
HOW DO I ASK FOR A STATE FAIR HEARING?
You must ask for a State Fair Hearing in writing within 120 days of getting the Notice of Appeal
Resolution. This includes both standard and expedited requests for a State Fair Hearing.
Requests for State Fair Hearings should be mailed to:
Arizona Complete Health-Complete Care Plan Attn: Grievance and Appeal Department
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1870 W. Rio Salado Parkway Tempe, AZ 85281
WHAT IS THE PROCESS FOR MY STATE FAIR HEARING?
You will receive a Notice of State Fair Hearing at least 30 days before your hearing is scheduled.
The Notice of State Fair Hearing is a written letter that will tell you:
• The time, place and nature of the hearing;
• The reason for the hearing;
• The legal and jurisdictional authority that requires the hearing; and
• The specific laws that are related to the hearing.
HOW IS MY STATE FAIR HEARING RESOLVED?
For standard State Fair Hearings, you will receive a written !H���S Director’s Decision no later
than 90 days after your appeal was first filed. This 90-day period does not include:
• Any timeframe extensions that you have requested; and
• The number of days between the date that you received the Notice of Appeal Resolution and the date your request for a State Fair Hearing was submitted.
The !H���S Director’s Decision will tell you the outcome of the State Fair Hearing and the final
decision about your services.
For expedited State Fair Hearings, you will receive a written !H���S Director’s Decision within
3 working days after the date that AHCCCS receives your case file and appeal information from
Arizona Complete Health-Complete Care Plan. AHCCCS will also try to call you to notify you of
the !H���S Director’s Decision/
WILL MY SERVICES CONTINUE DURING THE APPEAL/STATE FAIR HEARING PROCESS?
You may ask that the services you were already getting continue during the appeal process or
the State Fair Hearing process. If you want to keep getting the same services, you must ask for
your services to be continued in writing. If the result of the appeal or State Fair Hearing is not in
your favor, you may have to pay for the services received during the appeal or State Fair
Hearing process.
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MEMBERS DETERMINED TO HAVE A SERIOUS MENTAL ILLNESS
If you are a member that has been determined to have a Serious Mental Illness, please call !rizona �omplete Health-�omplete �are Plan and we can provide you additional information about your grievance and appeals rights;
Member Rights Our goal is to provide high-quality medical and behavioral health care. We also promise to
listen, treat you with respect, and understand your individual needs. Members have rights and
responsibilities. The following is a description of your rights as a Arizona Complete Health-
Complete Care Plan member.
DO YOU HAVE A MEDICARE PART D PLAN?
Every Medicare Part D plan must have an exception and appeal process. If you have Medicare
Part D Prescription Drug coverage and you file an exception or appeal, you may be able to get
a prescription drug that is not normally covered by your Part D plan. Contact your Part D plan
for help in filing an exception or appeal regarding your prescription drug coverage.
As a member, you have the right to:
➢ File a complaint about the managed care organization (Arizona Complete Health-
Complete Care Plan). Please call us at Member Services if you have any issues with your
care.
➢ Request information on the structure and operation of Arizona Complete Health-
Complete Care Plan or our subcontractors
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➢ You have the right to request information on whether or not Arizona Complete Health-
Complete Care Plan has Physician Incentive Plans (PIP) that affect the use of referral
services, the right to know the types of compensation arrangements Arizona Complete
Health-Complete Care Plan uses, the right to know whether stop-loss insurance is
required and the right to a summary of member survey results, in accordance with PIP
regulation. You can make your request for this information by calling the Arizona
Complete Health-Complete Care Plan Member Services. Know the types of
compensation arrangements Arizona Complete Health-Complete Care Plan uses
➢ Know whether stop-loss insurance is required
➢ Receive a summary of member survey results
➢ The right to be treated fairly regardless of race, religion, color, creed, national origin, disability, sexual orientation, sex, gender identity, age, marital status, ability to pay
➢ Health Care Privacy (Confidentiality) - There are laws about who can see your personal
health information with or without your permission. Substance abuse treatment and
communicable disease information (for example, HIV/AIDS information) cannot be
shared with others without your written permission.
To help arrange and pay for your care, there are times when your information is shared without
first getting your written permission. These times could include the sharing of information with:
➢ Physicians and other agencies providing health, social, or welfare services;
➢ Your medical primary care provider;
➢ Certain state agencies and schools following the law, involved in your care and
treatment, as needed; and
➢ Members of the clinical team involved in your care.
At other times, it may be helpful to share your personal health information with other agencies,
such as schools. Your written permission may be required before your information is shared.
There may be times that you want to share your health information with other agencies or
certain individuals who may be assisting you. In these cases, you can sign an Authorization for
the Release of Information Form, which states that your medical records, or certain limited
portions of your medical records, may be released to the individuals or agencies that you name
on the form. For more information about the Authorization for the Release of Information
Form, contact Arizona Complete Health-Complete Care Plan at 1-888-788-4408, TTY/TDY 711 or
go to our website at www.azcompletehealth.com/completecare
You can ask to see the health information in your medical record. You can also ask that the
record be changed if you do not agree with its contents. You can also receive one copy per year
of your medical record at no cost to you. Contact your provider or Arizona Complete Health-
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Complete Care Plan to ask to see or get a copy of your medical record. Arizona Complete
Health-Complete Care Plan Member Services can help you. Just call 1-888-788-4408, TTY/TDY
711 to request a copy. You will receive a response to your request within 30 days. If you receive
a written denial to your request, you will be provided with information about why your request
to obtain your medical record was denied and how you can seek a review of that denial.
Arizona Complete Health-Complete Care Plan has a Notice of Privacy Practices (NPP) available
at any time. You can access this NPP by visiting the Arizona Complete Health-Complete Care
Plan website, or calling customer service at 1-888-788-4408, TTY/TDY 711 to request a copy.
EXCEPTIONS TO CONFIDENTIALITY
There are times when we cannot keep information confidential. The following information is
not protected by the law:
➢ If you commit a crime or threaten to commit a crime at the program or against any
person who works at the program, we must call the police.
➢ If you are going to hurt another person, we must let that person know so that they can
protect themselves. We must also call the police.
➢ We must also report suspected child abuse to local authorities.
➢ If there is a danger that you might hurt yourself, we must try to protect you. If this
happens, we may need to talk to other people in your life or other service providers
(e.g., hospitals and other counselors) to protect you. Only necessary information to keep
you safe is shared.
➢ Coordination of care with school and state agencies - With your written consent,
coordination of care may take place with other types of programs and services such as
the Department of Economic Security, Division of Development Disabilities,
Rehabilitative Services Administration, Administrative Office of the Courts/Juvenile
Probation, Arizona Department of Corrections, Arizona Department of Juvenile
Corrections, Administrative Office of the Courts, and the Department of Education as
well as local schools and other local health departments or community service agencies
when applicable.
➢ A second opinion for a qualified health professional within the network, or have a
second opinion arranged outside the network, only if there is not adequate in-network
coverage at no cost to the enrollee
➢ Receive information on available treatment options and alternatives, presented in a
manner appropriate to your condition and ability to understand the information
➢ Be provided with information about formulating advance directives with your health
care providers.
➢ Request and receive annually, at no cost, a copy of your medical records.
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➢ Receive your request for medical records within thirty (30) days. This response will
either be a copy of your records, or a reason for denying your request. If a request is
denied, in whole or in part, we must give you a written denial within sixty (60) days that
includes the reason for the denial, your rights to disagree, and your rights to include
your amendment with any future disclosures of your health information as allowed by
law. Your right to access medical records may also be denied if the information is
psychotherapy notes, compiled for, or in a reasonable anticipation of a civil, criminal or
administrative action, protected health information subject to Federal Clinical
Laboratory Improvement Amendments of 1988 or exempt pursuant to 42 CFR Part 164.
➢ Amend or correct your medical records as allowed by law
➢ Be free from any restraint or seclusion used as a means of coercion, discipline,
convenience, or retaliation
➢ Receive information on beneficiary and plan information
➢ Be treated with respect, and recognition of your dignity and right to privacy. We
understand your need for privacy and confidentiality, including protection of any
information that identifies you
➢ Participate in decision-making regarding your health care, including the right to refuse
treatment from a provider and have a representative facilitate care or treatment
decisions when you are unable to do so
➢ Have a list of available providers as part of Arizona Complete Health-Complete Care
Plan’s Provider Directory, including those who speak a language other than English and
are able to accommodate members with disabilities
➢ Use any hospital or other setting for emergency care without approval
➢ Select a primary care physician (PCP) from Arizona Complete Health-Complete Care
Plan’s participating P�Ps
➢ For members in a HCBS or a behavioral health residential setting that have completed
an Advance Directive, the document must be kept confidential but be readily available.
For example: in a sealed envelope attached to the refrigerator
➢ Any restrictions on your freedom of choice among network providers
➢ Receive information in a language and format that you understand
➢ Be provided with information regarding grievance, appeals and request for hearing
➢ Have access to review medical records in accordance with applicable federal and state
laws
➢ Request a copy of the Notice of Privacy Practices at no cost to you. The notice describes
Arizona Complete Health-Complete Care Plan’s privacy practices and how we use health
information about you and when we may share that health information with others.
Your health care information will be kept private and confidential. It will be given out
only with your permission or if the law allows it.
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➢ Respect and Dignity
o Get your services in a safe environment;
o You can get behavioral and medical services that support your personal beliefs,
medical condition, and background in a language you understand
➢ Treatment Decisions
o Receive information on treatment options and alternatives, appropriate to your
condition, in a way that you are able to understand and allows you to participate in
decisions about your health care;
o Decide who you want with you during treatment and agree to or refuse treatment
services, unless the services are court ordered;
What is Fraud and !buse?
Fraud is any lie told on purpose that results in you or some other person receiving unnecessary benefits. This includes any act of fraud defined by Federal or State law.
Examples of Member Fraud include but are not limited to: ➢ Lending or selling your AHCCCS Identification Card to anyone. ➢ Changing prescriptions written by any of our providers. ➢ Selling prescription drugs. ➢ Giving incorrect information on your AHCCCS application.
Examples of Provider Fraud include but are not limited to: ➢ Use of the Medicaid system by someone who is inappropriate, unqualified, unlicensed
or has lost their license. ➢ Providing unnecessary medical services. ➢ Not meeting professional standards for health care. ➢ Billing for appointments that do not happen.
Abuse describes practices that, either directly or indirectly, result in unnecessary costs. Abuse includes but is not limited to the following:
Abuse by a Member consists of unnecessary costs to the program as a result of: ➢ Providing false materials or documents ➢ Leaving out important information
Abuse by a Provider consists of actions that are not wise business or medical practices and result in: ➢ Unnecessary costs to the program ➢ Payment for services that are not medically necessary ➢ Not meeting professional standards for health care ➢ Charging excessively for services or supplies.
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HOW TO REPORT FRAUD AND ABUSE:
If you suspect one of our providers or members of fraud and abuse, please contact Arizona Complete Health-Complete Care Plan at 1-888-788-4408 or TTY/TDY 711.
You may also report Fraud and Abuse to AHCCCS at 1-602-417-4000 or toll free at 1-800-654-
Penalties: A person who is suspected of fraud and/or abuse of the AHCCCS system will be reported to AHCCCS. Penalties for people involved in fraud and/or abuse may be both civil and criminal.
�ommunity Resources
TOBACCO EDUCATION AND PREVENTION
If you are thinking about quitting smoking, we can help you do this. You can enroll in a program to help you stop smoking through the Arizona Department of Health Services (ADHS).
➢ You can get free coaching from the !rizona Smokers’ Helpline (!SHLine) at 1-800-556-6222.
➢ You can go online at www.ashline.org. ➢ You can get help making a plan to quit at
https://www.azdhs.gov/preparedness/epidemiology-disease-control/smoke-free-arizona/index.php
Your plan covers many kinds of products to help you quit. These include prescription drugs and OTCs (over the counter). You must contact your Primary Care Provider (PCP) for any of these products, including OTCs. Your doctor will decide which one would be best for you. If you are under 18 years old, your doctor will need to get prior authorization (PA) for the drug you need. Your doctor will take care of this for you. Your plan covers up to a twelve week supply in a six month time period. The six month time period starts the date that you first get your drug from the pharmacy.
!LZHEIMER’S !SSO�I!TION
The !lzheimer’s !ssociation provides education and resources to those affected by !lzheimer’s disease. Phone: (800) 272-3900 Website: www.alz.org
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ARIZONA WOMEN INFANTS AND CHILDREN (WIC)
WIC provides food, breastfeeding education, and information on healthy diet to women who
are pregnant, infants, and children under five years old.
150 N. 18th Ave., Ste. 310, Phoenix, AZ 85007
Phone: 1‑800‑252‑5942
Website: www.azdhs.gov/azwic/
AZ SUICIDE PREVENTION COALITION
Arizona Suicide Prevention Coalition works to reduce suicidal acts in Arizona. Their mission is to change those conditions that result in suicidal acts in Arizona through awareness, intervention and action.
PO Box 10745 Phoenix, AZ 85064
Website: www.azspc.org
HEALTH-E-ARIZONA PLUS
AHCCCS and DES collaborated to develop a system to apply for AHCCCS Health Insurance, KidsCare, Nutrition Assistance and Cash Assistance benefits and to connect to the Federal Insurance Marketplace.
Website: www.healthearizonaplus.gov
AZLINKS.GOV
AzLinks.gov offers assistance and information on aging and disability. Use AzLinks.gov to plan
for the future or handle an immediate need. Our Az Links partner agencies in your community
are there to help.
Website: www.AzLinks.gov
HEALTHY FAMILIES ARIZONA
This program helps child-bearers have a healthy pregnancy and helps with child development,
nutrition, safety and other things. A community health worker will go to the pregnant
member’s home to give her information and help with any concerns that she might have. The
program starts while the member is pregnant, and can continue through the time that the baby
is 5 years old.
1789 W. Jefferson St., Phoenix, AZ 85007
Phone: 602‑542‑4791
Website: https://des.az.gov/services
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PIMA COUNCIL ON AGING
Pima Council on Aging advocates, plans, coordinates, develops and delivers home-and-
community based aging services for older adults and provides support assistance, accurate
information, and local resources connections for family caregivers.
8467 East Broadway Blvd.
Tucson, AZ 85710
Phone: (520) 790-7262
Website: https://www.pcoa.org/
AREA AGENCY ON AGING
Area Agency on Aging advocates, plans, coordinates, develops and delivers home-and-
community based aging services for older adults and provides support assistance, accurate
information, and local resources connections for family caregivers.
1366 East Thomas Road, Suite 108, Phoenix AZ 85014
Phone: (888) 783-7500
Website: https://www.aaaphx.org/
PINAL-GILA COUNCIL FOR SENIOR CITIZENS
Pinal-Gila Council for Senior Citizens advocates, plans, coordinates, develops and delivers
home-and-community based aging services for older adults and provides support assistance,
accurate information, and local resources connections for family caregivers.
8969 W. McCartney Road, Casa Grande, Arizona, 85194
Phone: (520) 836-2758
Website: http://www.pgcsc.org/
SEAGO AREA AGENCY ON AGING
South Eastern Arizona Governments Organizations Area Agency on Aging advocates, plans,
coordinates, develops and delivers home-and-community based aging services for older adults
and provides support assistance, accurate information, and local resources connections for
family caregivers.
Phone: (520- 432-2528 Ext. 220
Website: http://www.seago.org/aaa/index.html
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ARIZONA EARLY INTERVENTION PROGRAM (AZEIP)
The Arizona Early Intervention Program (AzEIP, pronounced Ay‑zip), helps families of children
with disabilities or developmental delays age birth to three years old. They provide support and
can work with their natural ability to learn. To get help or learn more about AzEIP resources,
call Arizona Complete Health-Complete Care Plan and ask for the Arizona Complete Health-
Complete Care Plan AzEIP coordinator.
Phone: 602‑532‑9960
Website: www.azdes.gov/AzEIP
ARIZONA HEAD START
Head Start is a great program that gets preschoolers ready for kindergarten. Preschoolers
enrolled in Head Start will get healthy snacks and meals too. Head Start offers these services
and more at no cost to you.
Website: www.azheadstart.org
NAMI ARIZONA (NATIONAL ALLIANCE ON MENTAL ILLNESS)
NAMI Arizona has a HelpLine for information on mental illness, referrals to treatment and community services, and information on local consumer and family self-help groups throughout Arizona. NAMI Arizona provides emotional support, education, and advocacy to people of all ages who are affected by mental illness. Phone: 480-994-4407 Website: http://www.namiarizona.org/
AzDHS Dump the Drugs AZ
App providing information on where to dispose of medications. Locate and get directions to the
nearest site to safely dispose of unwanted prescription drugs.
https://azdhs.gov/gis/dump-the-drugs-az/
MENTALLY ILL KIDS IN DISTRESS (MIKID)
MIKID provides support and help to families in Arizona with behaviorally challenged children, youth, and young adults/ MIKID offers information on children’s issues, internet access for parents, referrals to resources, support groups, educational speakers, holiday and birthday support for children in out of home placement, and parent-to-parent volunteer mentors. Phone: 520-882-0142 (Pima); 928-344-1983 (Yuma) Website: http://www.mikid.org/
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COMMUNITY INFORMATION AND REFERRAL
Community Information and Referral is a call center that can help you find many community
services.
Food banks, clothes, shelters, help to pay rent and utilities Health care, pregnancy health, help
when you or someone else is in trouble, support groups, counseling, and help with drug or
alcohol problems
Financial help, job training, transportation, education programs Adult day care, meals on
wheels, respite care, home health care, transportation, homemaker services Childcare, after
school programs, family help, summer camps and play programs, counseling, help with
learning, protective services
Phone: 2‑1‑1
Website: www.cir.org
CHILD AND FAMILY RESOURCES
Child and Family Resources Programs include:
Child Care Resource & Referral, where parents call to get a list of child care centers
The Center for Adolescent Parents where teens who have had a child can earn their high school
diploma or GED while receiving no cost, onsite childcare
Child & Family Resources Headquarters Sierra Vista
Angel Charity Building 3965 E. Foothills Drive
2800 E. Broadway Blvd. Suite E1
Tucson, AZ 85716 Sierra Vista, AZ 85635
(520) 881-8940 (520) 458-7348
Douglas Casa Grande Office
1065 F Avenue #4 1115 E. Florence Boulevard
Douglas, AZ 86426 Suite M
(520) 364-5014 Casa Grande, AZ 85122
(520) 518-5292 Safford
1491 W. Thatcher Boulevard Nogales
Suite 106 1827 N. Mastick Way Safford, AZ 85546 Nogales, AZ 85621 (928) 428-7231 (520) 281-9303
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Yuma
201 S. 3rd Ave. www.childfamilyresources.org
Yuma, AZ 85364
(928) 783-4003
(800) 929-8194
Low �ost/Sliding Scale Health �are Providers If you become ineligible for Medicaid and are not able to get other health insurance, you can
visit this website to look for clinics that provide free or low cost primary, mental, and dental
health services to people without health insurance.
https://www.azdhs.gov/prevention/health-systems-development/sliding-fee-
schedule/index.php#clinic-locations
!dvocacy Information
! healthcare advocate is someone who works to promote and protect people’s rights in the
healthcare system. Arizona Complete Health-Complete Care Plan partners with advocates
across Southern and Central Arizona to ensure your rights are upheld and your voice is heard.
Our advocacy team can help you through an appeal process on grievances, mediate problems
with your health care provider, and connect with advocacy organizations.
Some advocacy organizations that Arizona Complete Health-Complete Care Plan partners with
are as follows:
Arizona Center for Disability Law – Mental Health
The Arizona Center for Disability Law is dedicated to protecting the rights of individuals with
physical, mental, psychiatric, sensory and cognitive disabilities. You can contact them at (800)
922-1447 for more information.
National Alliance on Mental Illness
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NAMI, the National Alliance on Mental Illness, is the nation’s largest grassroots mental health
organization dedicated to building better lives for the millions of Americans affected by mental
illness. To learn more about their organization and advocacy programs call them at 1-800-950-
NAMI.
Arizona Coalition Against Sexual and Domestic Violence
The Arizona Coalition Against Sexual and Domestic Violence serve providers of direct services to
victims and survivors of sexual and domestic violence. Their purpose is:
➢ Increase public awareness about the issues of sexual and domestic violence
➢ Enhance the safety of and services for sexual and domestic violence victims and
survivors
➢ End sexual and domestic violence in Arizona communities
If you need help, please call the National Domestic Violence Hotline: 1-800-799-7233 (SAFE) or
TTY 1-800-787-3224.
Arizona Child and Family Advocacy Network
The Arizona Child and Family Advocacy Network (ACFAN) provides support, training and
guidance to all advocacy centers in Arizona and their professionals who coordinate services and
respond to family violence and sexual assault. Efforts are made to accommodate special needs
and multilingual populations.
ACFAN has Advocacy centers located throughout Arizona that are designed to provide onsite
services to child victims of either physical or sexual abuse as well as neglect. Some centers
provide services to adult victims of sexual assault, domestic violence, or vulnerable adult abuse.
For more information on these advocacy centers, you can visit their website at
http://acfan.net/ or call them at 1-928-458-0117.
Family Advocacy Center Services
The Family Advocacy Center (FAC) services include, but are not limited to:
➢ Crisis intervention
➢ Emergency needs assessment
➢ Safety planning
➢ 9-1-1 Phone
➢ Shelter access and emergency housing assistance
➢ Victim's rights education
➢ Current case status updates
➢ Referrals for long-term case management
➢ Short-term case management
➢ Education on domestic violence dynamics
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➢ Education learning how to navigate the criminal justice system
You can contact a FAC victim advocate to obtain help with services at 1-602-534-2120 or 1-888-
246-0303.
Special Assistance for members determined to have SMI
Special Assistance is a unique clinical designation providing support to members with an SMI
determination. Qualifying members must have an inability to communicate and/or participate
during treatment planning and have a qualifying mental and/or physical condition. When a
health home clinical team or other qualified assessor determines a member meets Special
Assistance criteria they notify the Office of Human Rights. The Office of Human Rights will
assign an individual to meet Special Assistance needs who advocates on behalf of the member
during treatment planning.
Arizona Complete Health-Complete Care Plan works in collaboration with the AHCCCS Office of
Human Rights to ensure members meeting Special Assistance criteria are appropriately
identified.
You can reach the Individual & Family Affairs team by calling Member Services at 1-888-788-
4408 (TTY/TDY: 711) and asking to speak to someone from the Individual & Family Affairs Team.
You can visit the AHCCCS Office of Human Rights page at:
https://www.azahcccs.gov/AHCCCS/HealthcareAdvocacy/ or call: 1-877-524-6882
Terms & Definitions
Appeal: To ask for review of a decision that denies or limits a service.
Copayment: Money a member is asked to pay for a covered health service, when the service is
given.
Durable Medical Equipment: Equipment and supplies ordered by a health care provider for a
medical reason for repeated use.
Emergency Medical Condition: An illness, injury, symptom or condition (including severe pain) that a reasonable person could expect that not getting medical attention right away would:
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• Put the person’s health in danger- or • Put a pregnant individual’s baby in danger- or • Cause serious damage to bodily functions; or • Cause serious damage to any body organ or body part.
Emergency Medical Transportation: See EMERGENCY AMBULANCE SERVICES
Emergency Ambulance Services: Transportation by an ambulance for an emergency condition.
Emergency Room Care: Care you get in an emergency room.
Emergency Services: Services to treat an emergency condition.
Excluded Services: See EXCLUDED
Excluded: Services that AHCCCS does not cover. Examples are services that are: • Above a limit, • Experimental, or • Not medically needed.
Grievance: A complaint that the member communicates to their health plan. It does not include a complaint for a health plan’s decision to deny or limit a request for services/
Habilitation Services and Devices: See HABILITATION
Habilitation: Services that help a person get and keep skills and functioning for daily living.
Health Insurance: Coverage of costs for health care services.
Home Health Care: See HOME HEALTH SERVICES
Home Health Services: Nursing, home health aide, and therapy services; and medical supplies, equipment, and appliances a member receives at home based on a doctor’s order/
Hospice Services: Comfort and support services for a member deemed by a Physician to be in the last stages (six months or less) of life.
Hospital Outpatient Care: Care in a hospital that usually does not require an overnight stay.
Hospitalization: Being admitted to or staying in a hospital.
Medically Necessary: A service given by a doctor, or licensed health practitioner that helps with health problem, stops disease, disability, or extends life.
Network: Physicians, health care providers, suppliers and hospitals that contract with a health
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plan to give care to members.
Non-Participating Provider: See OUT OF NETWORK PROVIDER
Out of Network Provider: A health care provider that has a provider agreement with AHCCCS but does not have a contract with your health plan. . You may be responsible for the cost of care for out-of-network providers.
Participating Provider: See IN-NETWORK PROVIDER
In-Network Provider: A health care provider that has a contract with your health plan.
Physician Services: Health care services given by a licensed physician.
Plan: See SERVICE PLAN
Service Plan: A written description of covered health services, and other supports which may include:
• Individual goals; • Family support services; • Care coordination; and • Plans to help the member better their quality of life.
Preauthorization: See PRIOR AUTHORIZATION
Prior Authorization: Approval from a health plan that may be required before you get a service. This is not a promise that the health plan will cover the cost of the service.
Premium: The monthly amount that a member pays for health insurance. A member may have other costs for care including a deductible, copayments, and coinsurance.
Prescription Drug Coverage: Prescription drugs and medications paid for by your health plan.
Prescription Drugs: Medications ordered by a health care professional and given by a pharmacist.
Primary Care Physician. ! doctor who is responsible for managing and treating the member’s health.
Primary Care Provider (PCP): A person who is responsible for the management of the member’s health care/ ! P�P may be a:
• Person licensed as an allopathic or osteopathic physician, or • Practitioner defined as a physician assistant licensed or • Certified nurse practitioner.
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Provider: A person or group who has an agreement with AHCCCS to provide services to AHCCCS
members.
Rehabilitation Services and Devices: See REHABILITATION
Rehabilitation: Services that help a person restore and keep skills and functioning for daily
living that have been lost or impaired.
Skilled Nursing Care: Skilled services provided in your home or in a nursing home by licensed
nurses or therapists.
Specialist: A doctor who practices a specific area of medicine or focuses on a group of patients.
Urgent Care: Care for an illness, injury, or condition serious enough to seek immediate care, but
not serious enough to require emergency room care.
Maternity �are Service Definitions Certified Nurse Midwife (CNM) is certified by the American College of Nursing Midwives
(ACNM) on the basis of a national certification examination and licensed to practice in Arizona
by the State Board of Nursing. CNMs practice independent management of care for pregnant
individuals and newborns, providing antepartum, intrapartum, postpartum, gynecological, and
newborn care, within a health care system that provides for medical consultation, collaborative
management, or referral management or referral.
High‑risk pregnancy refers to a pregnancy in which the child-bearer, fetus, or newborn is, or is
anticipated to be, at increased risk for morbidity or mortality before or after delivery. High risk
is determined using the Medical Insurance Company of Arizona (MICA) or American College of
Obstetricians and Gynecologists (ACOG) standardized medical risk assessment tools.
Licensed Midwife is an individual licensed by the Arizona Department of Health Services to
provide maternity care pursuant to Arizona Revised Statutes (A.R.S.) Title 36, Chapter 6, Article
7 and Arizona Administrative Code Title 9, Chapter 16 (This provider type does not include
certified nurse midwives licensed by the Board of Nursing as a nurse practitioner in midwifery
or physician assistants licensed by the Arizona Medical Board).
Maternity care includes identification of pregnancy, prenatal care, labor/delivery services, and
postpartum care.
Maternity care coordination consists of the following maternity care related activities:
determining the member’s medical or social needs through a risk assessment evaluation-
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developing a plan of care designed to address those needs; coordinating referrals of the
member to appropriate service providers and community resources; monitoring referrals to
ensure the services are received; and revising the plan of care, as appropriate.
Practitioner refers to certified nurse practitioners in midwifery, physician’s assistants, and
other nurse practitioners/ Physician’s assistants and nurse practitioners are defined in !/R/S/
Title 32, Chapters 25 and 15 respectively.
Postpartum care is the health care provided for a period of up to 60 days post‑ delivery. Family
planning services are included if provided by a physician or practitioner.
Preconception counseling services, as part of an annualvisit, are provided when medically
necessary. This counseling focuses on the early detection and management of risk factors
before pregnancy, and includes efforts to influence behaviors that can affect a fetus (even
before conception is confirmed), as well as regular health care. The purpose of preconception
counseling is to ensure that an individualis healthy prior to pregnancy. Preconception
counseling does not include genetic testing.
Prenatal care is the health care provided during pregnancy and is composed of three major
components:
➢ Early and continuous risk assessment ➢ Health education and promotion ➢ Medical monitoring, intervention, and follow-up
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Effective 07.01.2017
For help to translate or understand this, please call 1-888-788-4408 (TTY 711.)
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Si necesita ayuda para traducir o entender este texto, por favor llame al telefono.
1-888-788-4408 (TTY 711).
Interpreter services are provided free of charge to you.
Covered Entities Duties:
Arizona Complete Health is a Covered Entity as defined and regulated under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). Arizona Complete Health is required by law to
maintain the privacy of your protected health information (PHI), provide you with this Notice of our
legal duties and privacy practices related to your PHI, abide by the terms of the Notice that is
currently in affect and notify you in the event of a breach of your unsecured PHI.
This Notice describes how we may use and disclose your PHI. It also describes your rights to access,
amend and manage your PHI and how to exercise those rights. All other uses and disclosures of
your PHI not described in this Notice will be made only with your written authorization.
Arizona Complete Health reserves the right to change this Notice. We reserve the right to make the
revised or changed Notice effective for your PHI we already have as well as any of your PHI we
receive in the future. Arizona Complete Health will promptly revise and distribute this Notice
whenever there is a material change to the following:
o The Uses or Disclosures o Your rights o Our legal duties o other privacy practices stated in the notice.
We will make any revised Notices available the Arizona Complete Health Arizona website, located
below.
https://review-www.azcompletehealth.com/privacy-practices.html
Permissible Uses and Disclosures of Your PHI:
The following is a list of how we may use or disclose your PHI without your permission or
authorization:
• Treatment - We may use or disclose your PHI to a physician or other health care provider providing treatment to you, to coordinate your treatment among providers, or to assist us in making prior authorization decisions related to your benefits.
• Payment - We may use and disclose your PHI to make benefit payments for the health care services provided to you. We may disclose your PHI to another health plan, to a health care provider, or other entity subject to the federal Privacy Rules for their payment purposes. Payment activities may include
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o processing claims o determining eligibility or coverage for claims o issuing premium billings o reviewing services for medical necessity o performing utilization review of claims
• HealthCare Operations - We may use and disclose your PHI to perform our healthcare operations. These activities may include:
o providing customer services o responding to complaints and appeals o providing case management and care coordination o conducting medical review of claims and other quality assessment o improvement activities
In our healthcare operations, we may disclose PHI to business associates. We will have
written agreements to protect the privacy of your PHI with these associates. We may
disclose your PHI to another entity that is subject to the federal Privacy Rules. The entity
must also have a relationship with you for its healthcare operations. This includes the
following:
o quality assessment and improvement activities o reviewing the competence or qualifications of healthcare professionals o case management and care coordination o detecting or preventing healthcare fraud and abuse.
• Group Health Plan/Plan Sponsor Disclosures – We may disclose your protected health information to a sponsor of the group health plan, such as an employer or other entity that is providing a health care program to you, if the sponsor has agreed to certain restrictions on how it will use or disclose the protected health information (such as agreeing not to use the protected health information for employment-related actions or decisions).
Other Permitted or Required Disclosures of Your PHI:
• Fundraising Activities – We may use or disclose your PHI for fundraising activities, such as raising money for a charitable foundation or similar entity to help finance their activities. If we do contact you for fundraising activities, we will give you the opportunity to opt-out, or stop, receiving such communications in the future.
• Underwriting Purposes – We may use or disclosure your PHI for underwriting purposes, such as to make a determination about a coverage application or request. If we do use or disclose your PHI for underwriting purposes, we are prohibited from using or disclosing your PHI that is genetic information in the underwriting process.
• Appointment Reminders/Treatment Alternatives - We may use and disclose your PHI to remind you of an appointment for treatment and medical care with us or to provide you with information regarding treatment alternatives or other health-related benefits and services, such as information on how to stop smoking.
• As Required by Law - If federal, state, and/or local law requires a use or disclosure of your PHI, we may use or disclose your PHI information to the extent that the use or disclosure complies with such law and is limited to the requirements of such law. If two or more laws
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or regulations governing the same use or disclosure conflict, we will comply with the more restrictive laws or regulations.
• Public Health Activities - We may disclose your PHI to a public health authority for the purpose of preventing or controlling disease, injury, or disability. We may disclosure your PHI to the Food and Drug Administration (FDA) to ensure the quality, safety or effectiveness products or services under the jurisdiction of the FDA.
• Victims of Abuse and Neglect - We may disclose your PHI to a local, state, or federal government authority, including social services or a protective services agency authorized by law authorized by law to receive such reports if we have a reasonable belief of abuse, neglect or domestic violence.
• Judicial and Administrative Proceedings - We may disclose your PHI in judicial and administrative proceedings. We may also disclose it in response to the following:
o an order of a court o administrative tribunal o subpoena o summons o warrant o discovery request o similar legal request.
• Law Enforcement - We may disclose your relevant PHI to law enforcement when required to do so. For example, in response to a:
• o court order o court-ordered warrant o subpoena o summons issued by a judicial officer o grand jury subpoena
We may also disclose your relevant PHI to identify or locate a suspect, fugitive, material
witness, or missing person.
• Coroners, Medical Examiners and Funeral Directors - We may disclose your PHI to a coroner or medical examiner. This may be necessary, for example, to determine a cause of death. We may also disclose your PHI to funeral directors, as necessary, to carry out their duties.
• Organ, Eye and Tissue Donation - may disclose your PHI to organ procurement organizations. We may also disclose your PHI to those who work in procurement, banking or transplantation of:
o cadaveric organs o eyes o tissues
• Threats to Health and Safety - We may use or disclose your PHI if we believe, in good faith, that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public.
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• Specialized Government Functions - If you are a member of U.S. Armed Forces, we may disclose your PHI as required by military command authorities. We may also disclose your PHI:
o to authorized federal officials for national security o to intelligence activities o the Department of State for medical suitability determinations o for protective services of the President or other authorized persons
• Workers’ Compensation - We may disclose your PHI to comply with laws relating to workers’ compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
• Emergency Situations – We may disclose your PHI in an emergency situation, or if you are incapacitated or not present, to a family member, close personal friend, authorized disaster relief agency, or any other person previous identified by you. We will use professional judgment and experience to determine if the disclosure is in your best interests. If the disclosure is in your best interest, we will only disclose the PHI that is directly relevant to the person's involvement in your care.
• Inmates - If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official, where such information is necessary for the institution to provide you with health care; to protect your health or safety; or the health or safety of others; or for the safety and security of the correctional institution.
• Research - Under certain circumstances, we may disclose your PHI to researchers when their clinical research study has been approved and where certain safeguards are in place to ensure the privacy and protection of your PHI.
USES AND DISCLOSURES OF YOUR PHI THAT REQUIRE YOUR WRITTEN AUTHORIZATION
We are required to obtain your written authorization to use or disclose your PHI, with limited
exceptions, for the following reasons:
Sale of PHI – We will request your written authorization before we make any disclosure that is
deemed a sale of your PHI, meaning that we are receiving compensation for disclosing the PHI in
this manner.
Marketing – We will request your written authorization to use or disclose your PHI for marketing
purposed with limited exceptions, such as when we have face-to-face marketing communications
with you or when we provide promotional gifts of nominal value.
Psychotherapy Notes – We will request your written authorization to use or disclose any of you
psychotherapy notes that we may have on file with limited exception, such as for certain treatment,
payment or healthcare operation functions.
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INDIVIDUALS RIGHTS
The following are your rights concerning your PHI. If you would like to use any of the following
rights, please contact us using the information at the end of this Notice.
• Right to Revoke an Authorization - You may revoke your authorization at any time, the revocation of your authorization must be in writing. The revocation will be effective immediately, except to the extent that we have already taken actions in reliance of the authorization and before we received your written revocation.
• Right to Request Restrictions - You have the right to request restrictions on the use and disclosure of your PHI for treatment, payment or healthcare operations, as well as disclosures to persons involved in your care or payment of your care, such as family members or close friends. Your request should state the restrictions you are requesting and state to whom the restriction applies. We are not required to agree to this request. If we agree, we will comply with your restriction request unless the information is needed to provide you with emergency treatment. However, we will restrict the use or disclosure of PHI for payment or health care operations to a health plan when you have paid for the service or item out of pocket in full.
• Right to Request Confidential Communications - You have the right to request that we communicate with you about your PHI by alternative means or to alternative locations. This right only applies if the information could endanger you if it is not communicated by the alternative means or to the alternative location you want. You do not have to explain the reason is for your request, but you must state that the information could endanger you if the communication means or location is not changed. We must accommodate your request if it is reasonable and specifies the alternative means or location where you PHI should be delivered.
• Right to Access and Received Copy of your PHI - You have the right, with limited exceptions, to look at or get copies of your PHI contained in a designated record set. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your PHI. If we deny your request, we will provide you a written explanation and will tell you if the reasons for the denial can be reviewed and how to ask for such a review or if the denial cannot be reviewed.
• Right to Amend your PHI - You have the right to request that we amend, or change, your PHI if you believe it contains incorrect information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request for certain reasons, for example if we did not create the information you want amended and the creator of the PHI is able to perform the amendment. If we deny your request, we will provide you a written explanation. You may respond with a statement that you disagree with our decision and we will attach your statement to the PHI you request that we amend. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information. Right to Receive an Accounting of Disclosures - You have the right to receive a list of
instances within the last 6 years period in which we or our business associates disclosed your
PHI. This does not apply to disclosure for purposes of treatment, payment, health care
operations, or disclosures you authorized and certain other activities. If you request this
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accounting more than once in a 12-month period, we may charge you a reasonable, cost-
based fee for responding to these additional requests. We will provide you with more
information on our fees at the time of your request.
• Right to File a Complaint - If you feel your privacy rights have been violated or that we have violated our own privacy practices, you can file a complaint with us in writing or by phone using the contact information at the end of this Notice. You can also file a complaint with the Secretary of the U.S. Department of Health and Human
Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201 or calling 1-800-368-1019, (TTY: 1-866-788-4989) or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/.
WE WILL NOT TAKE ANY ACTION AGAINST YOU FOR FILING A COMPLAINT.
• Right to Receive a Copy of this Notice - You may request a copy of our Notice at any time by using the contact information list at the end of the Notice. If you receive this Notice on our web site or by electronic mail (e-mail), you are also entitled to request a paper copy of the Notice.
CONTACT INFORMATION
If you have any questions about this Notice, our privacy practices related to your PHI or how to
exercise your rights you can contact us in writing or by phone using the contact information listed
below.
Arizona Complete Health Attn: Privacy Official 1870 E. Rio Salado Parkway Tempe, AZ 85281 1-866-475-3129
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